Abstract

PURPOSE: Recent evidence demonstrated similar outcomes between nonsurgical and surgical management of displaced proximal humerus fractures. We analyzed treatment trends and performed a cost-minimization analysis comparing nonsurgical treatment, open reduction and internal fixation, reverse total shoulder arthroplasty, and hemiarthroplasty. We hypothesized that rates of surgical treatment have increased and that the costs associated with surgery are greater compared with nonsurgical management of proximal humerus fractures.METHODS: We used a US private-payer claims database of 22 million patient records from 2007 to 2016 to compare (1) cost for the episode of care from the payer perspective between each surgical group and nonsurgical treatment of proximal humerus fractures, and (2) annual trends and complication rates of each group. Cost data, including facility fees, physician fees, physical therapy, and clinic visits, were used to complete a cost-minimization analysis.RESULTS: Nonsurgical treatment was associated with lower average total costs compared with surgical intervention. Facility and physician fees accounted for most of this difference. Physical therapy costs and number of physical therapy visits were higher in each surgical group compared with nonsurgical treatment. Surgical treatment was associated with higher complications, revision rates, and length of stay. There was a small but statistically significant decrease in nonsurgical management of proximal humerus fractures between 2007 and 2016. No change was observed in rates of open reduction and internal fixation, whereas rates of reverse total shoulder arthroplasty increased and rates of hemiarthroplasty decreased.CONCLUSIONS: Nonsurgical management of proximal humerus fractures decreased during the study period. In the setting of treatment equipoise, cost-minimization analysis favors nonsurgical management of proximal humerus fractures. Surgical management is associated with higher complication rates, revision rates, and length of stay.TYPE OF STUDY/LEVEL OF EVIDENCE: Economic Decision Analysis IV.

Abstract

OBJECTIVE: Periprosthetic fractures of the distal femur can be challenging injuries to treat; nonunion rates of up to 22% have been reported. The purpose of this study was to determine the rate of complications and nonunion in a multicenter series, and to identify patient or surgical factors that were associated with nonunion.DESIGN: Retrospective comparative study SETTING: Three Level 1 trauma centers PATIENTS: Fifty-five patients with a periprosthetic distal femur fracture proximal to a total knee arthroplasty. Minimum follow up for inclusion was six months or until union or failure.INTERVENTION: Surgical fixation using a precontoured lateral locking plate MAIN OUTCOME MEASUREMENT: Fracture union was the primary outcome. Patient demographic and injury variables (age, comorbidities, fracture classification and characteristics) and surgical technique factors (mode of plate fixation, plate material, working length, screw density, and proximal screw type) were identified and compared between patients who developed a nonunion and those who did not. Regression analysis was performed to identify independent risk factors for nonunion.RESULTS: The overall rate of nonunion was 18% and the total complication rate was 24%. After additional surgery, 49 of 55 patients went on to heal (89%). There were no statistical differences in patient demographic or injury variables between the union and nonunion groups, and none of the variables studied were independent risk factors for nonunion in the regression analysis.CONCLUSIONS: In this series of 55 patients with periprosthetic distal femur fractures treated with precontoured lateral locking plates, 18% developed nonunion and the overall complication rate was 24%. No patient or surgical variables were identified as risk factors. Future research should seek to identify patients at high risk for complication and nonunion who could benefit from alternative fixation strategies or distal femoral replacement.

Abstract

Nitrogen-containing bisphosphonates (N-BPs), such as alendronate, are the most widely prescribed medications for diseases involving bone, with nearly 200 million prescriptions written annually. Recently, widespread use of N-BPs has been challenged due to the risk of rare but traumatic side effects such as atypical femoral fracture (AFF) and osteonecrosis of the jaw (ONJ). N-BPs bind to and inhibit farnesyl diphosphate synthase, resulting in defects in protein prenylation. Yet, it remains poorly understood what other cellular factors might allow N-BPs to exert their pharmacological effects. Here, we performed genome-wide studies in cells and patients to identify the poorly characterized gene, ATRAID Loss of ATRAID function results in selective resistance to N-BP-mediated loss of cell viability and the prevention of alendronate-mediated inhibition of prenylation. ATRAID is required for alendronate inhibition of osteoclast function, and ATRAID-deficient mice have impaired therapeutic responses to alendronate in both postmenopausal and senile (old age) osteoporosis models. Last, we performed exome sequencing on patients taking N-BPs that suffered ONJ or an AFF. ATRAID is one of three genes that contain rare nonsynonymous coding variants in patients with ONJ or an AFF that is also differentially expressed in poor outcome groups of patients treated with N-BPs. We functionally validated this patient variation in ATRAID as conferring cellular hypersensitivity to N-BPs. Our work adds key insight into the mechanistic action of N-BPs and the processes that might underlie differential responsiveness to N-BPs in people.

Abstract

OBJECTIVES: 1) To determine the effect of single versus dual plate metaphyseal fixation for pilon fractures on callus formation and reoperation rates, 2) to determine the effect of biomechanically matched versus unmatched fixation, and 3) to determine whether patient or surgical factors were independent predictors of bridging callus formation or need for reoperation.DESIGN: Retrospective comparative study.SETTING: Single level one trauma center.PATIENTS: Fifty patients with AO/OTA type C2 or C3 pilon fractures treated with plate fixation.INTERVENTION: Internal fixation with a plate and screw construct, with comparisons made between patients with single versus dual plate fixation, and patients treated with biomechanically matched or unmatched fixation.MAIN OUTCOME MEASUREMENTS: Modified RUST (mRUST) scores at three and six months and reoperation rate.RESULTS: At six months, mean mRUST scores were significantly lower in patients treated with dual metaphyseal plates compared to a single plate (8.7 vs 10.4, p=0.046) There were 15 open fractures; eight were treated with supplemental fixation, while seven were treated with single-column fixation. Open fracture (OR 51.05, p=0.008) was a risk factor for reoperation. Screw density between 0.4 and 0.5 was a protective factor against reoperation (OR 0.03, p=0.026). Biomechanically unmatched fixation did not affect mRUST scores or reoperation rates.CONCLUSIONS: Pilon fractures treated with a single plate had more callus formation six months after surgery compared to those treated with dual plate fixation, and there was no difference in reoperation rates. Screw density between 0.4-0.5 was protective against reoperation. These data may serve as the basis of future work to determine the ideal fixation construct for the frequently comminuted metaphysis in pilon fractures. Further work is necessary to determine whether callus formation in these injuries is desirable.LEVEL OF EVIDENCE: Three.

Abstract

Dynamization of fracture fixation constructs provides early rigidity for primary bone healing and late motion for secondary healing. A review of laboratory, animal, and clinical studies investigating the impact, and optimal timing, of dynamization is limited by lack of standardization across studies. However, in animal models, dynamization improves histologic and biomechanical properties compared with statically rigid or flexible controls. In animals, dynamization at 3 to 4 weeks showed improved histologic results. In clinical studies, it showed faster, stronger, and stiffer bone healing. Clinical success dynamizing external fixators and intramedullary nails suggests a role for late dynamization in other fixation types, such as bridge plating. [Orthopedics. 2020;43(3):e125-e133.].

Abstract

Effective fracture surgery requires contouring orthopaedic implants in multiple planes. The amount of force required for contouring is dependent on the amount and type of material contained within the plane to be altered. The type of contouring used depends on the desired plate function; for example, buttress mode often requires some degree of undercontouring, whereas compression plating may require prebending. Other reasons to contour a plate include matching patient anatomy either to maximize fixation options or to reduce implant prominence. Precontoured plates can be convenient and help to facilitate soft-tissue friendly techniques but have the potential to introduce malreduction if the plate position and fit are not carefully monitored.

Abstract

PURPOSE: This study examined the outcomes and complications after treatment of unstable distal clavicle fractures with hook or locking plate fixation.METHODS: A retrospective search was performed of all acute distal clavicle fractures treated with open reduction and internal fixation from 2009 to 2019 at a Level I trauma center. Patients were separated into hook and locking plate fixation groups. Rates of union, complications, and reoperation, were extracted. QuickDASH (Disabilities of Arm, Shoulder, and Hand) scores were determined.RESULTS: Thirty-one patients met the inclusion criteria and were included in the study. Of these, 12 patients were treated with hook plates and 19 were treated with locking plates. All fractures healed without loss of reduction, regardless of implant selection. There were no immediate or long-term complications in either group. 83% of hook plate patients underwent planned implant removal, while 37% of locking plate patients requested implant removal secondary to irritation. QuickDASH scores were comparable and excellent in both groups.CONCLUSIONS: Hook and locking plate fixation for Neer type-II and type-V distal clavicle fractures have comparably high rates of union. Hook plates were removed routinely per protocol, while locking plates were removed only if symptomatic and occurred significantly less often.

Abstract

PURPOSE: The purpose of this study was to evaluate the safety and efficacy of using lower profile 2.4/2.4mm and 2.0/2.4mm dual mini-fragment plate constructs for fixation of diaphyseal clavicle fractures.METHODS: This was a retrospective case series of all displaced diaphyseal clavicle fractures treated with 2.4/2.4 and 2.0/2.4 dual mini-fragment plate constructs at a single level-one trauma center. Postoperative complications and fracture healing rates were recorded. A subset of patients with long-term follow up was used to determine the rate of reoperation for symptomatic implant removal.RESULTS: All 36 identified fractures healed without loss of reduction or implant failure. There was one superficial infection and no deep infections or cases of wound dehiscence. Twenty patients from the entire cohort had longer-term follow up available to assess the reoperation rate for symptomatic implant removal. Two patients (10%) underwent symptomatic implant removal, and one patient with retained implants was planning on future removal due to soft-tissue irritation; this combined to a projected reoperation rate of 15% for symptomatic implant removal.CONCLUSION: Dual mini-fragment plating of diaphyseal clavicle fractures, using 2.4/2.4mm and 2.0/2.4mm plate combinations, creates a lower profile construct that reliably maintains fracture reduction to healing, and has a low rate of reoperation for symptomatic implant removal.

Abstract

Patient satisfaction plays a prominent role in modern orthopaedic care, reimbursement, and quality assessment, even if it runs contrary to the "standard of care." The literature shows that routine early radiographs after acute fracture care have no impact on clinical decision-making or patient outcomes, but little is known about their effect on patient satisfaction and understanding of their injuries. We hypothesized that eliminating these radiographs would negatively influence patient satisfaction scores with their clinic visit.One hundred patients were prospectively enrolled after acute fracture fixation. Half the patients obtained radiographs at the 2-week follow-up visit, whereas the other half did not. All patients completed a satisfaction survey about their clinic visit.No difference was observed between the groups in overall satisfaction with the clinic visit (P = 0.62) or complications. However, patients with radiographs were more satisfied with the surgeon's explanations of their injury and progression (P = 0.03).Eliminating routine early postoperative radiographs had no effect on overall patient satisfaction with the clinic visit, but it did affect satisfaction with the surgeon's explanation of their injury. This could save time, money, and radiation exposure without adversely affecting patient outcome or satisfaction, but an equivalent educational tool should be identified for clinic visits.

Abstract

Patient-reported outcome measures (PROMS) are being increasingly used as a quality of care metric. However, the validity and consistency of PROMS remain undefined. The study sought to determine whether Foot and Ankle Ability Measure (FAAM) scores improve after patients complete motor tasks evaluated on the survey and to examine the relationship between depression and self-efficacy and FAAM scores or change in scores. We conducted a prospective comparison study of adults with isolated foot, ankle, or distal tibia fractures treated operatively at level I trauma center. Twenty-seven patients completed the FAAM survey at the first clinic visit after being made weightbearing as tolerated (mean 3 months). Patients then completed 6 motor tasks queried on FAAM (standing, walking without shoes, squatting, stairs, up to toes), followed by a repeat FAAM and General Self-Efficacy scale (GSE) and Patient Health Questionnaire-2 (PHQ-2) instruments. FAAM scores before and after intervention; GSE and PHQ-2 scores compared with baseline FAAM and change in FAAM scores. Performing motor tasks significantly improved postintervention scores for squatting (P=.044) and coming up to toes (P=.012), the 2 most strenuous tasks. No difference was found for the remaining tasks. Higher depression ratings correlated with worse FAAM scores overall (P < .05). Higher self-efficacy ratings correlated with increase in FAAM Sports subscale postintervention (P=.020). FAAM scores are influenced by performing motor tasks. Self-reported depression influences baseline FAAM scores and self-efficacy may influence change in FAAM scores. Context and patient factors (modifiable and nonmodifiable) affect PROM implementation, with implications for clinical care, reimbursement models, and use of quality measure.

Abstract

BACKGROUND: Septic arthritis is an orthopedic emergency requiring immediate surgical intervention. Current diagnostic standard of care is an invasive joint aspiration. Aspirations provide information about the inflammatory cells in the sample within a few hours, but there is often ambiguity about whether the source is infectious (e.g. bacterial) or non-infectious (e.g. gout). Cultures can take days to result, so decisions about surgery are often made with incomplete data. Novel diagnostics are thus needed. The "Sepsis MetaScore" (SMS) is an 11-mRNA host immune blood signature that can distinguish between infectious and non-infectious acute inflammation. It has been validated in multiple cohorts across heterogeneous clinical settings.AIM: To study whether the SMS holds diagnostic validity in determining the etiology of acute arthritis.METHODS: We conducted a blinded, prospective, non-interventional clinical study of the SMS. All patients undergoing work-up for a septic primary joint were enrolled. Patients proceeded through the normal standard-of-care pathway, including joint aspiration and inflammatory labs [white blood cell (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)]. Venous blood was also drawn into PAX gene RNA-stabilizing tubes and mRNAs were measured using Nano String nCounter. SMS was calculated blinded to clinical results.RESULTS: A total of 20 samples were included, of which 11 were infected based on aspiration or intra-operative cultures. The SMS had an area under the ROC curve (AUROC) of 0.87 for separating infectious from non-infectious conditions. For comparison, the AUROCs for ESR = 0.58, CRP = 0.6, and WBC = 0.59. At 100% sensitivity for infection, the specificity of the SMS was 40%, meaning nearly half of non-septic patients could have been ruled out for further intervention.CONCLUSION: In this pilot study, SMS showed a high level of diagnostic accuracy in predicting septic joints compared to other diagnostic biomarkers. This quick blood test could be an important tool for early, accurate identification of acute septic joints and need for emergent surgery, improving clinical care and healthcare spending.

Abstract

OBJECTIVES: To biomechanically compare plated constructs using nonlocking bone-screw-fasteners with interlocking threads versus locking screws with traditional buttress threads in geriatric female bone.METHODS: Eleven matched pairs of proximal and distal segments of geriatric female cadaveric tibias were used to create a diaphyseal fracture model. Nonlocking bone-screw-fasteners or locking buttress threaded screws were applied to a locking compression plate on the anterolateral aspect of the tibia placed in bridge mode. Specimens were subjected to incrementally increasing cyclic axial load combined with constant cyclic torsion. Total cycles to failure served as a primary outcome measure, with failure defined as 2mm of displacement or 10 degrees of rotation. Secondary outcome measures included initial stiffness in compression and torsion determined from preconditioning testing and overall rigidity as determined by maximum peak-to-peak axial and rotational motion at 500 cycle intervals during cyclic testing. Group comparisons were made using paired Student's t-tests. Significance was set at p<0.05.RESULTS: Bone-screw-fastener constructs failed at an average of 40,63622,151 cycles and locking screw constructs failed at an average of 37,7738433 cycles, without difference between groups (p==0.610). Total cycles to failure was higher in the bone-screw-fasteners group for 7 tibiae out of the eleven matched pairs tested. During static and cyclic testing, bone-screw-fastener constructs demonstrated increased initial torsional stiffness (7.6%) and less peak-to-peak displacement and rotation throughout the testing cycle(p<0.05).CONCLUSIONS: In female geriatric bone, constructs fixed with bone-screw-fasteners incorporate multiplanar interlocking thread geometry and performed similarly to traditional locked plating. These novel devices may combine the benefits of both nonlocking and locking screws when plating geriatric bone.

Abstract

PURPOSE: Eliciting patient preferences is one part of the shared decision-making process-a process of decision making focused on the values and preferences of the patient. We evaluated the usability and feasibility of a point-of-care conjoint analysis tool for preference elicitation for shared decision making in the treatment of distal radius fractures in patients over the age of 55 years.METHODS: Twenty-seven patients 55 years of age or older with a displaced distal radius fracture were recruited from a hand and upper extremity clinic. A conjoint analysis tool was created describing the attributes of care (eg, return of grip strength) of surgical and nonsurgical treatment. This tool was administered to patients to determine their preferences for the treatment attributes when choosing between surgical and nonsurgical treatment. Patients completed a System Usability Scale (SUS) to evaluate usability, and time to complete the tool was measured to evaluate feasibility.RESULTS: Patients considered the conjoint analysis tool to be usable (SUS, 91.4; SD, 10.9). Mean time to complete the tool was 5.1 minutes (SD, 1.4 minutes). The most important attributes driving the decision for surgical treatment were return of grip strength at 1 year and time spent in a cast or brace. The most important attributes driving the decision for nonsurgical treatment were use of anesthesia during treatment and return of grip strength at 1 year.CONCLUSIONS: A point-of-care conjoint analysis tool for distal radius fractures in patients 55 years and older can be used to elicit patient preferences to inform the shared decision-making process. Further investigation evaluating the effect of preference elicitation on treatment choice, involvement in decision making, and patient-reported outcomes are needed.CLINICAL RELEVANCE: A conjoint analysis tool is a simple, structured process physicians can use during shared decision making to highlight trade-offs between treatment options and elicit patient preferences to inform treatment choices.

Abstract

Radiographic imaging is integral to the diagnosis and treatment of orthopedic injuries. Previous studies have shown that orthopedists consistently underestimate the price of implants, but their knowledge of imaging charges is unknown. This study evaluated whether orthopedic residents and faculty could accurately estimate charges of imaging modalities at their respective institutions. A survey with 10 common imaging studies was sent to 8 academic level I trauma centers. Participants estimated the total charge of each imaging modality. This was compared with the actual charge at their institution. Seven centers produced 162 responders: 74 faculty and 88 residents. The differences between the estimated cost and the billing charge were calculated and broken down by training level and imaging modality. Overall, imaging charges were underestimated by 31% (P

Abstract

In this video, we demonstrate application of a bridge plate by limited open technique for fixation of a proximal tibial metaphyseal fracture. Although intramedullary nailing remains our preferred surgical technique for treatment of most extra-articular fractures of the proximal tibia, we find bridge plating by limited open technique to be an important alternative option for select fracture patterns not amenable to intramedullary nailing.

Abstract

The burden of psychosocial problems, including substance abuse, is high among trauma patients. Use of illicit substances is often noted during urine toxicology screening on admission and can delay surgery because of concerns for an interaction with anesthesia. Methamphetamine theoretically has potential to increase perioperative anesthetic risks. However, the authors are unaware of any studies documenting increased rates of cardiovascular complications in the perioperative period among orthopedic trauma patients. This study sought to determine the rate of cardiovascular complications in these patients. The authors reviewed the medical records of all patients between 2013 and 2018 who underwent orthopedic trauma surgery at two level I trauma centers in the setting of a methamphetamine-positive urine toxicology screening prior to surgery. Information on demographics, injury, type of surgical intervention, and incidence of perioperative cardiovascular and overall medical complications prior to discharge was recorded. Ninety-four patients were included in the study (mean age, 44 years; range, 16-78 years). Twenty-six (28%) patients had multiple injuries. Thirteen (14%) patients had debridement and/or provisional stabilization of an open or unstable fracture, 18 (19%) had treatment for an infection, and 63 (67%) had definitive fracture surgery. The overall rates of perioperative cardiovascular complications and perioperative medical complications were 2.1% and 3.2%, respectively. This study provides both a baseline understanding of the complication rate for methamphetamine-positive orthopedic trauma patients during general anesthesia and justification for larger multicenter studies to further investigate this topic. [Orthopedics. 2019; 42(4):192-196.].

Abstract

Senior medical students interested in pursuing careers in orthopaedic surgery participate in orthopaedic rotations around the country. These rotations are an important part of the application process because they allow students to demonstrate their work ethic and knowledge and learn more about the fit and culture of the residency program. Although knowledge and technical ability are important, several less tangible factors also contribute to success. These include maintaining situational awareness and a positive attitude, putting forth an appropriate effort, preparing effectively, and critically evaluating one's own performance. Attention to these details can help maximize the student's chance for a successful rotation. The hosting program and faculty can further facilitate a successful rotation by setting appropriate expectations, orienting the student to the program, carefully selecting appropriate services and faculty, and providing dedicated education to the student.

Abstract

Treatment of anterior pelvic ring injuries involves both acute stabilization during the initial resuscitation and definitive fixation. Definitive management has evolved substantially over the past 40 years with improved patient mobilization and long-term outcomes. Although its use has recently declined, external fixation remains a favorable option in certain situations. Symphyseal plating is the preferred technique for stabilization of symphyseal diastasis because of superior stability and low morbidity. Ramus screws can be effective for simple ramus fractures but require a careful technique because of the proximity of neurovascular structures. The subcutaneous internal fixator provides a good option for obese patients in whom external fixation would be poorly tolerated. Regardless of fixation strategy, posterior ring reduction and stabilization is crucial.

Abstract

OBJECTIVES: To assess the current portfolio of quality measures and candidate quality measures that address orthopaedic trauma surgery.DATA SOURCES: We systematically reviewed the National Quality Forum, the Agency for Healthcare Research and Quality, and the Quality Payment Program for quality measures relevant to fracture surgery. We also searched MEDLINE/PubMed, Embase/Scopus, and Cochrane libraries.DATA EXTRACTION: Clinical practice guidelines were included as candidate quality measures if their development was in accordance with the Institute of Medicine criteria for development of clinical practice guidelines, were based on consistent clinical evidence including at least one Level I study, and carried the strongest possible recommendation by the developing body. We categorized the measures as structure, process, or outcome domains according to the framework described by Donabedian.DATA SYNTHESIS: From the 3809 articles initially identified and screened, a total of 189 combined quality or candidate quality measures were extracted from our review. With regard to the Donabedian framework, there were a total of 7% (13/189) structure, 52% process (99/189), and 41% (77/189) outcome measures identified.CONCLUSIONS: As quality measures progressively inform reimbursement in value based healthcare models, quality measures evaluating the care of patients sustaining a fracture will become increasingly relevant to orthopaedic trauma surgeons.

Abstract

OBJECTIVE: To evaluate the fit of distal femur locking plates. Secondarily, we sought to compare plate fit among patients with and without a total knee arthroplasty (TKA).DESIGN: We retrospectively reviewed full-length femur radiographs of patients who underwent primary TKA.SETTING: All patients underwent TKA at a large university hospital.INTERVENTION: Standard length pre-contoured distal femur locking plates from four manufacturers were digitally templated onto each patient's pre- and post-TKA radiographs.MAIN OUTCOME MEASUREMENTS: The maximum distance from the plate to the lateral femoral cortex (plate-bone distance) was measured in the metaphyseal region. Mean plate-bone distances were compared between manufacturers and between pre and post-TKA radiographs.RESULTS: All implants tested were undercontoured in all patients. Plate-bone distances ranged from 6.6 0.4 mm to 8.0 0.4 mm (mean standard error) pre-TKA and 8.2 0.3 mm to 8.6 0.3 mm after TKA, indicating worse fit after arthroplasty (p < 0.001). There were also inter-manufacturer differences, with Synthes and Smith & Nephew implants demonstrating the lowest plate-bone distances in the pre- and post-TKA groups, respectively. Proportionally, plate-bone increase was greater in the female cohort (16%) compared to the male cohort (8%).CONCLUSIONS: There was a plate-bone mismatch for the distal femur locking plates tested in this study, due to undercontouring of the implants. After patients underwent TKA, poor implant fit was exacerbated. Surgeons must be aware of the potential for deformity if the proximal segment is brought into contact with the implant. These finding may help optimize implant design for the treatment of periprosthetic distal femur fractures.LEVEL OF EVIDENCE: V.

Abstract

Patient satisfaction plays a prominent role in modern orthopaedic care, reimbursement, and quality assessment, even if it runs contrary to the "standard of care." The literature shows that routine early radiographs after acute fracture care have no impact on clinical decision-making or patient outcomes, but little is known about their effect on patient satisfaction and understanding of their injuries. We hypothesized that eliminating these radiographs would negatively influence patient satisfaction scores with their clinic visit.One hundred patients were prospectively enrolled after acute fracture fixation. Half the patients obtained radiographs at the 2-week follow-up visit, whereas the other half did not. All patients completed a satisfaction survey about their clinic visit.No difference was observed between the groups in overall satisfaction with the clinic visit (P = 0.62) or complications. However, patients with radiographs were more satisfied with the surgeon's explanations of their injury and progression (P = 0.03).Eliminating routine early postoperative radiographs had no effect on overall patient satisfaction with the clinic visit, but it did affect satisfaction with the surgeon's explanation of their injury. This could save time, money, and radiation exposure without adversely affecting patient outcome or satisfaction, but an equivalent educational tool should be identified for clinic visits.

Abstract

To map the proximal ulnar articular margins and ensure safe extraarticular placement of implants.Ten fresh frozen adult elbow cadaver specimens were obtained. Radio opaque wire was applied to the articular margin of the articular facets and the central trochlear ridge of the proximal ulna. Fluoroscopic images were obtained demonstrating the articular facet margins. Radiographic measurements were performed and used to identify relative safe screw zones.All specimens demonstrated marked extension of the ulnar and radial facets dorsal to the central trochlear ridge. The dorsal extent of the ulnar facets from the central trochlear ridge averaged 9.7 mm (range, 7.9-13 mm; SD, 1.5 mm) and 6.2 mm (range, 3.4-9.4 mm; SD, 1.9 mm) respectively. The average footprint of the posterior ulnar facet occupied 44% (+/-4.9%) of the total ulnar height from the dorsal cortex to the trochlear ridge.The articular margins of the anterior and posterior facets of the proximal ulna are challenging to identify radiographically. A surgical "at risk zone" exists within 9.7 mm from the radiographic margin of the central trochlear ridge. Implants placed within this zone have the potential to violate the articular surface.

Abstract

To assess bounds of shared decision making in orthopaedic surgery, we conducted an exploratory study to examine the extent to which patients want to be involved in decision making in the management of a musculoskeletal condition.One hundred fifteen patients at an orthopaedic surgery clinic were asked to rate preferred level of involvement in 25 common theoretical clinical decisions (passive [0], semipassive [1 to 4], equally shared involvement between patient and surgeon [5], semiactive [6 to 9], active [10]).Patients preferred semipassive roles in 92% of decisions assessed. Patients wanted to be most involved in scheduling surgical treatments (4.75 2.65) and least involved in determining incision sizes (1.13 1.98). No difference exists in desired decision-making responsibility between patients who had undergone orthopaedic surgery previously and those who had not. Younger and educated patients preferred more decision-making responsibility. Those with Medicare desired more passive roles.Despite the importance of shared decision making on delivering patient-centered care, our results suggest that patients do not prefer to share all decisions.

Abstract

BACKGROUND: Surgical site infections (SSIs) pose a significant surgical complication. Application of closed-incision negative-pressure therapy (ciNPT) has been associated with reduced SSI rates in published literature. This meta-analysis examines the effect of ciNPT use over closed incisions in reducing SSIs versus traditional dressings.METHODS: A systematic literature search using PubMed, The Cochrane Library, OVID, EMBASE, ScienceDirect, and QUOSA was performed focusing on publications between January 1, 2005, and April 30, 2018. Characteristics of study participants, surgical procedure, type of dressing used, duration of treatment, incidence of SSI, and length of follow-up were extracted. Weighted odds ratios and 95% CIs were calculated to pool study and control groups in each publication for analysis. Treatment effects were combined using Mantel-Haenszel odds ratios as the summary statistics, and a fixed-effects model was used for each analysis performed. The chi-square test was used to statistically assess heterogeneity. For each meta-analysis performed, the more conservative random-effects models were conducted as sensitivity analyses.RESULTS: For all meta-analyses (randomized controlled trial only, observational studies only, colorectal/abdominal, obstetrics, lower extremity, groin/vascular, cardiac), heterogeneity tests were nonsignificant (P > 0.05). All fixed-effects meta-analyses were significant in favor of ciNPT use over traditional dressings (P < 0.05). When the random-effects analyses were performed, all analyses except obstetrics remained significant (P < 0.05).CONCLUSION: For all meta-analyses performed using the fixed-effects approach, ciNPT usage demonstrated a statistically significant reduction in incidence of SSI relative to traditional dressings.

Abstract

Fracture healing is a complex process of many coordinated biological pathways. This system can go awry resulting in nonunion, which leads to significant patient morbidity. The Hedgehog (Hh) signaling pathway is upregulated in fracture healing. We hypothesized that the Hh signaling pathway can be pharmacologically modulated to positively affect fracture healing. Diaphyseal femur fractures were created in elderly mice (18 months, C57BL/6 females), which have a blunted and delayed healing response compared to younger mice, and were stabilized with intramedullary pins. To activate the Hh pathway we targeted the receptor Smoothened using an agonist (Hh-Ag1.5 [Hh-Ag]) and compared this to a vehicle control. Expression of Hh target genes were significantly increased in the fracture callus of the agonist group compared to controls, indicating pathway activation. Expression of osteogenic and chondrogenic-related genes was greatly upregulated in fracture callus versus intact femora, although Hh agonist treatment did not consistently enhance this response. Blindly graded, radiographic callus healing scores were significantly higher in the Hh-Ag groups at post operative day (POD) 14, indicating earlier callus bridging. On microCT, Hh-Ag treatment led to greater callus volume (+40%) and bone volume (+25%) at POD21. By day 14, callus vascularity, as assessed by 3D microCT angiography vessel volume, was 85% greater in the Hh-Ag group. Finally, mechanical strength of the calluses in the Hh-Ag groups was significantly greater than in the control groups at POD21. In conclusion, systemic administration of a Hh agonist appears to improve the osseous and vascular healing responses in a mouse fracture healing-impaired model. 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Abstract

Posttraumatic avascular necrosis (AVN) is osteonecrosis from vascular disruption, commonly encountered after fractures of the femoral neck, proximal humerus, talar neck, and scaphoid. These locations have a tenuous vascular supply; the diagnosis, risk factors, natural history, and treatment are reviewed. Fracture nonunion only correlates with AVN in the scaphoid. In the femoral head, the risk is increased for displaced fractures, but the time to surgery and open versus closed treatment do not seem to influence the risk. Patients with collapse are frequently symptomatic, and total hip arthroplasty is the most reliable treatment. In the humeral head, certain fracture patterns correlate with avascularity at the time of injury, but most do not go on to develop AVN due to head revascularization. Additionally, newer surgical approaches and improved construct stability appear to lessen the risk of AVN. The likelihood of AVN of the talar body rises with increased severity of talar injury. The development of AVN corresponds with a worse prognosis and increases the likelihood of secondary procedures. In proximal pole scaphoid fractures, delays in diagnosis and treatment elevate the risk of AVN, which is often seen in cases of nonunion. The need for vascularized versus nonvascularized bone grafting when repairing scaphoid nonunions with AVN remains unclear.

Abstract

INTRODUCTION: Increased overlap in the scope of practice between orthopaedic surgeons and podiatrists has led to increased podiatric treatment of foot and ankle injuries. However, a paucity of studies exists in the literature comparing orthopaedic and podiatric outcomes following ankle fracture fixation.METHODS: Using an insurance claims database, 11,745 patients who underwent ankle fracture fixation between 2007 and 2015 were retrospectively evaluated. Patient data were analyzed based on the provider type. Complications were identified by the International Classification of Diseases, Ninth Revision, codes, and revision surgeries were identified by the Current Procedural Terminology codes. Complications analyzed included malunion/nonunion, infection, deep vein thrombosis, and rates of irrigation and debridement. Risk factors for complications were compared using the Charlson Comorbidity Index.RESULTS: Overall, 11,115 patients were treated by orthopaedic surgeons and 630 patients were treated by podiatrists. From 2007 to 2015, the percentage of ankle fractures surgically treated by podiatrists had increased, whereas that treated by orthopaedic surgeons had decreased. Surgical treatment by podiatrists was associated with higher malunion/nonunion rates among all types of ankle fractures. No differences in complications were observed in patients with unimalleolar fractures. In patients with bimalleolar or trimalleolar fractures, treatment by a podiatrist was associated with higher malunion/nonunion rates. Patients treated by orthopaedic surgeons versus podiatrists had similar comorbidity profiles.DISCUSSION: Surgical treatment of ankle fractures by orthopaedic surgeons was associated with lower rates of malunion/nonunion when compared with that by podiatrists. The reasons for these differences are likely multifactorial but warrants further investigation. Our findings have important implications in patients who must choose a surgeon to surgically manage their ankle fracture, as well as policymakers who determine the scope of practice.LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Abstract

OBJECTIVES: To describe the inferior retinacular artery (IRA) as encountered from an anterior approach, to define its intra-articular position and to define a safe zone for buttress plate fixation of femoral neck fractures.METHODS: Thirty hips (15 fresh cadavers) were dissected via an anterior (Modified Smith-Petersen) approach following common femoral artery injection (India ink, blue latex). The origin of the IRA from the medial femoral circumflex artery (MFCA) and the course to its terminus were dissected. The IRA position relative to the femoral neck was described using a clock face system: 12:00 cephalad, 3:00 anterior, 6:00 caudad, 9:00 posterior.RESULTS: The IRA originated from the MFCA and traveled within Weitbrecht's ligament in all hips. The IRA positions were 7:00 (n=13), 7:30 (n=15), and 8:00 (n=2). The IRA was 0:30 anterior to (n=24) or at the same clock face position (n=6) as the lesser trochanter. The mean intra-articular length was 20.4 mm (range 11 to 65, SD 9.1), and the mean extra-articular length was 20.5 mm (range 12 to 31, SD 5.1).CONCLUSIONS: The intra-articular course of the IRA lies within Weitbrecht's ligament between the femoral neck clock face positions of 7:00 and 8:00. A medial buttress plate positioned at 6:00 along the femoral neck is anterior to the location of the IRA and does not endanger the blood supply of the femoral head. The improved understanding of the IRA course will facilitate preservation during intra-articular approaches to the femoral neck and head.

Abstract

Suspected fractures are among the most common reasons for patients to visit emergency departments (EDs), and X-ray imaging is the primary diagnostic tool used by clinicians to assess patients for fractures. Missing a fracture in a radiograph often has severe consequences for patients, resulting in delayed treatment and poor recovery of function. Nevertheless, radiographs in emergency settings are often read out of necessity by emergency medicine clinicians who lack subspecialized expertise in orthopedics, and misdiagnosed fractures account for upward of four of every five reported diagnostic errors in certain EDs. In this work, we developed a deep neural network to detect and localize fractures in radiographs. We trained it to accurately emulate the expertise of 18 senior subspecialized orthopedic surgeons by having them annotate 135,409 radiographs. We then ran a controlled experiment with emergency medicine clinicians to evaluate their ability to detect fractures in wrist radiographs with and without the assistance of the deep learning model. The average clinician's sensitivity was 80.8% (95% CI, 76.7-84.1%) unaided and 91.5% (95% CI, 89.3-92.9%) aided, and specificity was 87.5% (95 CI, 85.3-89.5%) unaided and 93.9% (95% CI, 92.9-94.9%) aided. The average clinician experienced a relative reduction in misinterpretation rate of 47.0% (95% CI, 37.4-53.9%). The significant improvements in diagnostic accuracy that we observed in this study show that deep learning methods are a mechanism by which senior medical specialists can deliver their expertise to generalists on the front lines of medicine, thereby providing substantial improvements to patient care.

Abstract

Critical bone defects pose a formidable orthopaedic problem in patients with bone loss. We developed a preclinical model based on the induced membrane technique using a synthetic graft to replace autograft for healing critical bone defects. Additionally, we used a novel osteoconductive scaffold coupled with a synthetic membrane to evaluate the potential for single-stage bone regeneration. Three experimental conditions were investigated in critical femoral defects in rats. Group A underwent a two-stage procedure with insertion of a polymethylmethacrylate (PMMA) spacer followed by replacement with a 3D printed polycaprolactone(PCL)/beta-tricalcium phosphate (beta-TCP) osteoconductive scaffold after 4 weeks. Group B received a single-stage PCL/beta-TCP scaffold wrapped in a PCL-based microporous polymer film creating a synthetic membrane. Group C received a single-stage bare PCL/beta-TCP scaffold. All groups were examined by serial radiographs for callus formation. After 12 weeks, the femurs were explanted and analyzed with micro-CT and histology. Mean callus scores tended to be higher in Group A. Group A showed statistically significant greater bone formation on micro-CT compared with other groups, although bone volume fraction was similar between groups. Histology results suggested extensive bone ingrowth and new bone formation within the macroporous scaffolds in all groups and cell infiltration into the microporous synthetic membrane. This study supports the use of a critical size femoral defect in rats as a suitable model for investigating modifications to the induced membrane technique without autograft harvest. Future investigations should focus on bioactive synthetic membranes coupled with growth factors for single-stage bone healing. This article is protected by copyright. All rights reserved.

Abstract

OBJECTIVES: This cadaveric study sought to evaluate the accuracy of syndesmotic reduction using direct visualization via an anterolateral approach compared to palpation of the syndesmosis through a laterally based incision.METHODS: Ten cadaveric specimens were obtained and underwent baseline CT scans. Subsequently, a complete syndesmotic injury was simulated by transecting the anterior inferior tibiofibular ligament (AITFL), posterior tibiofibular ligament (PITFL), transverse ligament, interosseous membrane, and deltoid ligament. Three orthopaedic trauma surgeons were then asked to reduce each syndesmosis using direct visualization via an anterolateral approach. Specimens were then stabilized and underwent post-reduction CT scans. Fixation was then removed, the anterolateral exposure closed, and the surgeons were then asked to reduce the syndesmosis using palpation only via a direct lateral approach. Specimens were again instrumented and underwent post-reduction CT scans. Two tailed paired t-tests were used to compare reductions with baseline scans with significance set at p<0.05.RESULTS: There was no statistically significant difference between reduction via direct visualization or palpation via lateral approach when compared with baseline scans. Although measurements did not reach significance, there was a tendency towards external rotation, and anteromedial translation with direct visualization and a trend towards fibular external rotation and posterolateral translation with palpation.CONCLUSIONS: There is no difference in reduction quality using direct visualization or palpation to assess the syndesmosis. Surgeons may therefore choose either technique when reducing syndesmotic injures based on personal preference and other injury factors.

Abstract

Intramedullary nailing is often the treatment of choice for fractures of the tibia, but postoperative knee pain is common after this procedure. Potential etiologies include implant prominence, injury to intra-articular structures, patellar tendon or fat pad injury, damage to the infrapatellar branch of the saphenous nerve, and altered biomechanics. Depending on the etiology, described treatment options include observation, implant removal, assessment and treatment of injured intra-articular structures, and selective denervation. Careful attention to appropriate starting point and implant selection combined with more recently described semiextended nailing techniques may aid in prevention of knee pain.

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OBJECTIVE: We asked the following questions: 1. Does the use of an structured review instrument (SRI) at journal club increase presentation quality, as measured objectively by a standardized evaluation rubric? 2. Does SRI use increase the time required to prepare for journal club? 3. Does SRI use positively impact presenter perceptions about confidence while presenting, satisfaction, and journal club effectiveness, as measured by postparticipation surveys?DESIGN: A prospective study was designed in which a grading rubric was developed to evaluate journal club presentations. The rubric was applied to 24 presentations at journal clubs prior to introduction of the SRI. An SRI was developed and distributed to journal club participants, who were instructed to use it to prepare for journal club. The grading rubric was then used to assess 25 post-SRI presentations and scores were compared between the pre- and post-SRI groups. Presentations occurred at either trauma, pediatrics, or spine subspecialty journal clubs. Participants were also surveyed regarding time requirements for preparation, perceptions of confidence while presenting, satisfaction, and perceptions of overall club effectiveness.SETTING: A single academic center with an orthopaedic surgery residency program.PARTICIPANTS: Resident physicians in the department of orthopaedic surgery.RESULTS: Mean presentation scores increased from 14.0 5.9 (mean standard deviation) to 24.4 5.2 after introduction of the SRI (p < 0.001). Preparation time decreased from a mean of 47 minutes to 40 minutes after SRI introduction (p=0.22). Perceptions of confidence, satisfaction, and club effectiveness among trainees trended toward more positive responses after SRI introduction (confidence: 63% positive responses pre-SRI vs 72% post-SRI, p=0.73; satisfaction: 64% vs 91%, p=0.18; effectiveness: 64% vs 91%, p=0.19).CONCLUSIONS: The use of a structured review instrument to guide presentations at orthopaedic journal club increased presentation quality, and there was no difference in preparation time. There were trends toward improved presenter confidence, satisfaction, and perception of journal club effectiveness. SRI utilization at orthopaedic journal club may be an effective method for increasing the quality of journal club presentations. Future work should examine the relationship between presentation quality and overall club effectiveness.

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To describe a novel technique using preoperative computed tomography (CT) to plan clamp tine placement along the trans-syndesmotic axis (TSA). We hypothesized that preoperative CT imaging provides a reliable template on which to plan optimal clamp tine positioning along the TSA, reducing malreduction rates compared with other described techniques.CT images of 48 cadaveric through-knee specimens were obtained, and the TSA was measured as well as the optimal position of the medial clamp tine. The syndesmosis was then fully destabilized. Indirect clamp reductions were performed with the medial clamp tine placed at positions 10 degrees anterior to the TSA, along the TSA, and at both 10 and 20 degrees posterior to the TSA. The specimens were then separately reduced using manual digital pressure and palpation alone. CT was performed after each clamp and manual reduction.On average, reduction clamp tines were within 3 2 degrees of the desired angle and within 5% 4% of the templated location along the tibial line for all clamp reduction attempts. Palpation and direct visualization produced the overall lowest malreduction rates in all measurements: 4.9% and 3.0%, respectively. Off-axis clamping 10 degrees anterior or 20 degrees posterior to the patient-specific TSA demonstrated an increased overall malreduction rate: 15.8% and 11.3%, respectively. Significantly more over-compression occurred when a reduction clamp was used versus manual digital reduction alone (8.6% vs. 0%).Reduction clamp placement directly along an optimal clamping vector can be facilitated by preoperative CT measurements of the uninjured ankle. However, even in this setting, the use of reduction clamps increases the risk for syndesmotic malreduction and over-compression compared with manual digital reduction or direct visualization.

Abstract

The purpose of this study was to design and validate a novel stiffness-measuring device using locked plating of distal femur fractures as a model.All patients underwent a laterally-based approach, with a bridging locked construct after indirect reduction. A custom and calibrated intraoperative stiffness device was applied and the stiffness of the construct was blindly recorded. Fourteen of twenty-seven patients enrolled with distal femur fractures (AO/OTA 33A and 33C) completed the study. Correlations between stiffness and callus formation, working length, working length/plate length ratio, number of distal locking screws, and fracture pattern were explored.Callus and modified radiographic union scale in tibias scores as a linear function of stiffness did not correlate (R2=0.06 and 0.07, respectively). Construct working length and working length to plate length ratio did not correlate to stiffness (R2=0.18 and 0.16 respectively). A combined delayed and nonunion rate was 14%. Lower extremity measure scores were not statistically different when comparing delayed and nonunion with healed fractures.The lack of correlation may have been due to the mechanical properties of the plate itself and its large contribution to the overall stiffness of the construct. To our knowledge, clinically relevant stiffness has not been described and this study may provide some estimates. This methodology and these preliminary findings may lay the groundwork for further investigations into this prevalent clinical problem. Other parameters not investigated may play a key role such as body mass index and bone mineral density.Diagnostic/Prognostic Level II.

Abstract

BACKGROUND: Shared decision-making between patients and physicians involves educating the patient, providing options, eliciting patient preferences, and reaching agreement on a decision. There are different ways to measure shared decision-making, including patient involvement, but there is no consensus on the best approach. In other fields, there have been varying relationships between patient-perceived involvement and observed patient involvement in shared decision-making. The relationship between observed and patient-perceived patient involvement in decision-making has not been studied in orthopaedic surgery.QUESTIONS/PURPOSES: (1) Does patient-perceived involvement correlate with observed measurements of patient involvement in decision-making in orthopaedic surgery? (2) Are patient demographics associated with perceived and observed measurements of patient involvement in decision-making?METHODS: We performed a prospective, observational study to compare observed and perceived patient involvement in new patient consultations for eight orthopaedic surgeons in subspecialties including hand/upper extremity, total joint arthroplasty, spine, sports, trauma, foot and ankle, and tumor. We enrolled 117 English-literate patients 18 years or older over an enrollment period of 2 months. A member of the research team assessed observed patient involvement during a consultation with the Observing Patient Involvement in Decision-Making (OPTION) instrument (scaled 1-100 with higher scores representing greater involvement). After the consultation, we asked patients to complete a questionnaire with demographic information including age, sex, race, education, income, marital status, employment status, and injury type. Patients also completed the Perceived Involvement in Care Scale (PICS), which measures patient-perceived involvement (scaled 1-13 with higher scores representing greater involvement). Both instruments are validated in multiple studies in various specialties and the physicians were blinded to the instruments used. We assessed the correlation between observed and patient-perceived involvement as well as tested the association between patient demographics and patient involvement scores.RESULTS: There was weak correlation between observed involvement (OPTION) and patient-perceived involvement (PICS) (r = 0.37, p < 0.01) in decision-making (mean OPTION, 28.7, SD 7.7; mean PICS, 8.43, SD 2.3). We found a low degree of observed patient involvement despite a moderate to high degree of perceived involvement. No patient demographic factor had a significant association with patient involvement.CONCLUSIONS: Further work is needed to identify the best method for evaluating patient involvement in decision-making in the setting of discordance between observed and patient-perceived measurements. Knowing whether it is necessary for (1) actual observable patient involvement to occur; or (2) a patient to simply believe they are involved in their care can inform physicians on the best way to improve shared decision-making in their practice.LEVEL OF EVIDENCE: Level II, therapeutic study.

Abstract

BACKGROUND: In distal radius fracture repair, complications often lead to reoperation and increased cost. We examined the trends and complications in open reduction internal fixation of distal radius fractures across hand specialist and non-hand specialist surgeons.METHODS: We examined claims data from the Humana administrative claims database between 2007 and 2016. International Classification of Disease, 9th Edition and Current Procedural Terminology codes were searched related to distal radius fractures repaired by open reduction internal fixation. Patients were filtered based on initial treatment by a hand specialty or non-hand specialty surgeon. Complications were reported within 1year of surgical treatment in the following distinct categories: non-union, malunion, extensor/flexor tendon repair, CRPS, infection. Descriptive statistics were reported.RESULTS: Hand specialists accounted for 182 procedures compared with 7708 procedures by non-hand specialty orthopaedic or general surgeons. There was an increase in the total number of procedures performed by hand specialists across the years of study, with a higher percentage of intra-articular cases completed by hand specialists (80.7%) compared to non-hand specialists (70.1%). Overall, the complication rates of hand specialists (6.5%) were higher than that of non-specialists (4.7%).CONCLUSIONS: The results of this study demonstrate a small difference in overall complications for open reduction internal fixation of distal radius fractures by hand specialists in comparison to non-specialists despite treating a higher percentage of intra-articular fractures. Future work controlling for factors unaccounted for in claims-based analyses, such as fracture complexity, patient comorbidities, and surgeon factors are needed.TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Abstract

OBJECTIVE: To determine how the utilization of open versus percutaneous treatment of posterior pelvic ring injuries in early career orthopaedic surgeons has changed over time.METHODS: Case log data from surgeons testing in the trauma subspecialty for Part II of the ABOS examination from 2003 to 2015 were evaluated. CPT codes for percutaneous fixation (27216) and open fixation (27218) of the posterior pelvic ring were evaluated using a regression analysis.RESULTS: A total of 377 candidates performed 2,095 posterior ring stabilization procedures (1,626 percutaneous, 469 open). Total case volume was stable over time (beta=-1.7 (1.1), p=.14). There was no significant change in the number of posterior pelvic ring fracture surgery cases performed per candidate per test year (beta= 0.1 (0.1), p=.50). The proportion of posterior pelvic ring cases performed percutaneously increased significantly from 49% in 2003 to 79% in 2015 (beta= 1.0 (0.4), p=.03). There was a significant decrease in the number of open cases reported per candidate (beta= -0.07 (0.03), p=.008).DISCUSSION AND CONCLUSION: Early career orthopaedic surgeons are performing more percutaneous fixation of the posterior pelvic ring and less open surgery. The impact of this change in volume on surgeon proficiency is unknown and warrants additional research.

Abstract

To evaluate whether scientific abstracts selected for podium presentation at the Orthopaedic Trauma Association (OTA) Annual Meeting differ based on the program committee size and/or the proportion of abstracts each committee member evaluates.Abstract scores from the Orthopaedic Trauma Association program committee from 2010 through 2016 were obtained. All members (range, 8-9) reviewed each clinical abstract (range, 506-778) each year in a blinded fashion. The 90 top-scoring abstracts were considered "accepted" for this study. To determine the effect of reducing the committee size, all possible combinations of reviewers for each possible committee size were modeled. To determine the effect of reducing the number of abstracts each member reviewed, we used Monte Carlo simulation with 100 cycles to generate possible combinations of 1-9 reviewers for each abstract. Mean percent agreement with the actual selection was the primary outcome.The mean percent agreement progressively declined from 90.2% with 1 less committee member to 56.7% with only a single reviewer. For each reduction in the number of committee members, 4.4% agreement was lost. If all committee members were retained but the number of reviewers per abstract was reduced from 8 to 1, the mean percent agreement declined from 88.8% to 43.0%. Each reduction in reviewers per abstract reduced the mean percent agreement 6.3%.The findings inform program committees striving to balance the trade-off between an acceptable reduction in agreement, given a reduction in the program committee size or the proportion of abstracts each committee member evaluates.

Abstract

INTRODUCTION: Tibial plateau widening in the setting of fracture is an indication for surgical treatment, and restoring width is an important goal of surgery. In order to identify and correct pathological widening, the width of the normal tibial plateau must first be defined. The aim of this study was to establish normative data for the width of the tibial plateau relative to the distal femur to enable surgeons to identify and correct pathological widening in the setting of tibial plateau fracture.MATERIALS AND METHODS: Fifty-one uninjured anteroposterior (AP) knee radiographs and 11 XR and CT scans of lateral tibial plateau fractures were retrospectively reviewed. The distances measured included maximal distal femoral width, femoral articular width, tibial articular width, and lateral plateau widening.RESULTS: On average, lateral plateau widening was +0.022.03 mm, indicating that the most lateral aspect of the tibial plateau is collinear with the most lateral aspect of the lateral epicondyle of the femur. In the fracture population, average widening was 7.133.59 mm on XR and 6.573.34 mm on CT, with an absolute difference between XR and CT of 1.190.66 mm.CONCLUSIONS: This study is the first to define the radiographic anatomy of the proximal tibia quantitatively. In the setting of tibial plateau fracture, residual widening of 2.1 mm could be within normal variation. However, the authors consider widening>2.1 mm pathological. These values can be used for assessing pathological widening of tibial plateau fractures. This article is protected by copyright. All rights reserved.

Abstract

Fracture healing is a complex process of many coordinated biological pathways. This system can go awry resulting in nonunion, which leads to significant patient morbidity. The Hedgehog (Hh) signaling pathway is upregulated in fracture healing. We hypothesized that the Hh signaling pathway can be pharmacologically modulated to positively affect fracture healing. Diaphyseal femur fractures were created in elderly mice (18 months, C57BL/6 females), which have a blunted and delayed healing response compared to younger mice, and were stabilized with intramedullary pins. To activate the Hh pathway we targeted the receptor Smoothened using an agonist (Hh-Ag1.5 [Hh-Ag]) and compared this to a vehicle control. Expression of Hh target genes were significantly increased in the fracture callus of the agonist group compared to controls, indicating pathway activation. Expression of osteogenic and chondrogenic-related genes was greatly upregulated in fracture callus vs. intact femora, although Hh agonist treatment did not consistently enhance this response. Blindly graded, radiographic callus healing scores were significantly higher in the Hh-Ag groups at post operative day (POD) 14, indicating earlier callus bridging. On microCT, Hh-Ag treatment led to greater callus volume (+40%) and bone volume (+25%) at POD21. By day 14, callus vascularity, as assessed by 3D microCT angiography vessel volume, was 85% greater in the Hh-Ag group. Finally, mechanical strength of the calluses in the Hh-Ag groups was significantly greater than in the control groups at POD21. In conclusion, systemic administration of a Hh agonist appears to improve the osseous and vascular healing responses in a mouse fracture healing-impaired model. This article is protected by copyright. All rights reserved.

Abstract

Critical-sized bone defects are defined as those that will not heal spontaneously within a patient's lifetime. Current treatment options include vascularized bone grafts, distraction osteogenesis, and the induced membrane technique. The induced membrane technique is an increasingly utilized method with favorable results including high rates of union. Tissue engineering holds promise in the treatment of large bone defects due to advancement of stem cell biology, novel biomaterials, and 3D bioprinting. In this review, we provide an overview of the current operative treatment strategies of critical-sized bone defects as well as the current state of tissue engineering for such defects.

Abstract

Fracture surgeons do a great job of managing bone issues, but they may overlook the associated soft tissue injuries that play a significant role in the final outcome after musculoskeletal injury. The soft tissue reconstruction ladder can help guide reconstructive procedures based on the least complex procedure that allows the best chance of fracture healing. Muscle injury, volume loss, and deconditioning occur with traumatic injury and during the recovery phase. Neuromuscular stimulation, nutrition, and strength training are potential ways to aid in recovery. Complex periarticular knee injuries have a high rate of associated soft tissue injuries that may affect outcome if associated with knee instability. Identifying and addressing these injuries can increase the likelihood of a good outcome. Articular cartilage loss can make articular reconstruction impossible. Large fresh osteoarticular allografts can be a reconstructive option. Addressing all the damaged structures involved with a fracture may be the next step in improving patient outcomes.

Abstract

A substantial proportion of fractures can present with nonunion, and the management of nonunion continues to present a challenge for orthopaedic surgeons. A variety of biological, mechanical, patient, and injury factors can contribute to the occurrence of nonunion, and often the cause of nonunion may be multifactorial. Successful management often requires assessment and treatment of more than one of these factors. This article reviews common factors that may contribute to nonunion including infection, impaired biology, and metabolic disorders. In addition, new and evolving strategies for diagnosing the cause and effectively treating nonunion including the diagnosis of infection, metabolic workup, bone grafting, cell-based therapies, and biological adjuvants are reviewed and discussed.

Abstract

Use of percutaneous clamps are often helpful tools to aid reduction and intramedullary nailing of distal tibial spiral diaphyseal fractures. However, the anterior and posterior neurovascular bundles are at risk without careful clamp placement. We describe our preferred technique of percutaneous clamp reduction for distal spiral tibial fractures with a distal posterolateral fracture spike, with care to protect the adjacent neurovascular structures. We also investigated the relationship between these neurovascular structures and the site of common percutaneous clamp placement. Preoperative CT images of surgically managed patients who sustained this specific common fracture pattern (distal third spiral diaphyseal tibia fracture with a posterolateral fragment) were retrospectively reviewed. On CT, we extrapolated the ideal virtual clamp site on the posterolateral fracture fragment to facilitate reduction. The average distance of this clamp position from the anterior neurovascular bundle was 14 mm (SD= 7.6), with a range of 6 mm to 32 mm. The average distance of the clamp site from the posterior neurovascular bundle was 19 mm (SD= 6.1), with a range of 11 mm to 30 mm. In 31% of patients, the distal fragment's apex extended anterior to the interosseous membrane, and in 69% the apex was posterior to the interosseous membrane. We also describe our preferred surgical technique with percutaneous clamping and tibial nailing, which involves sliding the posterolateral tine of the percutaneous clamp along the lateral tibial cortex to prevent neurovascular bundle injury.

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This work aims at providing guidance through systematic experimental characterization, for the design of 3D printed scaffolds for potential orthopaedic applications, focusing on fused deposition modeling (FDM) with a composite of clinically available polycaprolactone (PCL) and -tricalcium phosphate (-TCP). First, we studied the effect of the chemical composition (0% to 60% -TCP/PCL) on the scaffold's properties. We showed that surface roughness and contact angle were respectively proportional and inversely proportional to the amount of -TCP, and that degradation rate increased with the amount of ceramic. Biologically, the addition of -TCP enhanced proliferation and osteogenic differentiation of C3H10. Secondly, we systematically investigated the effect of the composition and the porosity on the 3D printed scaffold mechanical properties. Both an increasing amount of -TCP and a decreasing porosity augmented the apparent Young's modulus of the 3D printed scaffolds. Third, as a proof-of-concept, a novel multi-material biomimetic implant was designed and fabricated for potential disk replacement.

Abstract

To evaluate whether objective syndesmosis reduction predicts functional outcomes and pain scores in patients with operatively treated syndesmotic injuries at a minimum 1-year follow-up.Prospective Cohort.Urban Level I Trauma Center.Sixty-nine patients with operatively treated syndesmotic injuries were initially identified and consented for inclusion in the study. Nine patients were excluded perioperatively. Twelve patients were lost to follow-up. Forty-eight patients with operatively treated unilateral syndesmotic injuries were available and participated at the final follow-up.Trans-syndesmotic stabilization with either 1 or 2 quadricortical position screws. Postoperatively, bilateral ankle computed tomography scans were obtained to objectively assess syndesmosis reduction accuracy.Olerud-Molander Ankle Score, Short Musculoskeletal Function Assessment Dysfunction Index and Bother Index, and Numeric Pain Rating Scales at a minimum 1-year postoperative follow-up.At 1-year follow-up, there was no significant difference in functional outcomes between reduced and malreduced groups at the 1.5-, 2-, and 3-mm thresholds for linear measurements. Similarly, there was no functional difference between the reduced and malreduced groups for rotational malreductions at a 10 or 15 degrees threshold. Patients with state-sponsored insurance (Medicaid) had significantly worse functional scores and pain scores when compared with the groups with private insurance, Medicare, or no insurance.At 1-year follow-up, functional outcomes were not related to objective measures of syndesmosis reduction.Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Abstract

A well-reduced femoral neck fracture is more likely to heal than a poorly reduced one, and increasing the quality of the surgical exposure makes it easier to achieve anatomic fracture reduction. Two open approaches are in common use for femoral neck fractures, the modified Smith-Petersen and Watson-Jones; however, to our knowledge, the quality of exposure of the femoral neck exposure provided by each approach has not been investigated.(1) What is the respective area of exposed femoral neck afforded by the Watson-Jones and modified Smith-Petersen approaches? (2) Is there a difference in the ability to visualize and/or palpate important anatomic landmarks provided by the Watson-Jones and modified Smith-Petersen approaches?Ten fresh-frozen human pelvi underwent both modified Smith-Petersen (utilizing the caudal extent of the standard Smith-Petersen interval distal to the anterosuperior iliac spine and parallel to the palpable interval between the tensor fascia lata and the sartorius) and Watson-Jones approaches. Dissections were performed by three fellowship-trained orthopaedic traumatologists with extensive experience in both approaches. Exposure (in cm) was quantified with calibrated digital photographs and specialized software. Modified Smith-Petersen approaches were analyzed before and after rectus femoris tenotomy. The ability to visualize and palpate seven clinically relevant anatomic structures (the labrum, femoral head, subcapital femoral neck, basicervical femoral neck, greater trochanter, lesser trochanter, and medial femoral neck) was also recorded. The quantified area of the exposed proximal femur was utilized to compare which approach afforded the largest field of view of the femoral neck and articular surface for assessment of femoral neck fracture and associated femoral head injury. The ability to visualize and palpate surrounding structures was assessed so that we could better understand which approach afforded the ability to assess structures that are relevant to femoral neck fracture reduction and fixation.After controlling for age, body mass index, height, and sex, we found the modified Smith-Petersen approach provided a mean of 2.36 cm (95% confidence interval [CI], 0.45-4.28 cm; p = 0.015) additional exposure without rectus femoris tenotomy (p = 0.015) and 3.33 cm (95% CI, 1.42-5.24 cm; p = 0.001) additional exposure with a tenotomy compared with the Watson-Jones approach. The labrum, femoral head, subcapital femoral neck, basicervical femoral neck, and greater trochanter were reliably visible and palpable in both approaches. The lesser trochanter was palpable in all of the modified Smith-Petersen and none of the Watson-Jones approaches (p < 0.001). All modified Smith-Petersen approaches (10 of 10) provided visualization and palpation of the medial femoral neck, whereas visualization of the medial femoral neck was only possible in one of 10 Watson-Jones approaches (p < 0.001) and palpation was possible in eight of 10 Watson-Jones versus all 10 modified Smith-Petersen approaches (p = 0.470).In the hands of surgeons experienced with both surgical approaches to the femoral neck, the modified Smith-Petersen approach, with or without rectus femoris tenotomy, provides superior exposure of the femoral neck and articular surface as well as visualization and palpation of clinically relevant proximal femoral anatomic landmarks compared with the Watson-Jones approach.Open reduction and internal fixation of a femoral neck fracture is typically performed in a young patient (< 60 years old) with the objective of obtaining anatomic reduction that would not be possible by closed manipulation, thus enhancing healing potential. In the hands of surgeons experienced in both approaches, the modified Smith-Petersen approach offers improved direct access for reduction and fixation. Higher quality reductions and fixation are expected to translate to improved healing potential and outcomes. Although our experimental results are promising, further clinical studies are needed to verify if this larger exposure area imparts increased quality of reduction, healing, and improved outcomes compared with other approaches. The learning curve for the exposure is unclear, but the approach has broad applications and is frequently used in other subspecialties such as for direct anterior THA and pediatric septic hip drainage. Surgeons treating femoral neck fractures with open reduction and fixation should familiarize themselves with the modified Smith-Petersen approach.

Abstract

INTRODUCTION: The purpose of this study was to evaluate the effectiveness of Factor Xa inhibitors (XaI) for thromboprophylaxis following hip fracture surgery in a large cohort of patients, and compare XaI against warfarin and enoxaparin.METHODS: Patients undergoing hip fracture surgery from 2007 to 2015 were identified in a large claims database. Patients prescribed warfarin, XaI, or enoxaparin within 2 weeks of surgery were identified and grouped into cohorts. Medical comorbidities and complication incidences, including deep venous thrombosis (DVT), pulmonary embolism (PE), and bleeding complications were calculated. Chi-square analysis was performed and adjusted residuals calculated to determine significant differences.RESULTS: DVT rates were significantly different between groups at thirty days only (5.03% warfarin, 2.91% XaI, 3.48% enoxaparin, p=0.047). PE rates were significantly different at all time points; enoxaparin had the lowest rates. There were no differences in the rates of other complications.DISCUSSION: XaI are an option for thromboprophylaxis in hip fracture patients, although their possible decreased effectiveness against PE compared to enoxaparin should be considered.CONCLUSIONS: This study compares the effectiveness of Factor Xa inhibitors to warfarin and enoxaparin for hip fracture patients, using a large national database. In this study, Factor Xa inhibitors had similar effectiveness for DVT prophylaxis compared to these agents.

Abstract

Fracture healing recapitulates many aspects of developmental osteogenesis. The hedgehog (Hh) signaling pathway, essential to skeletal development, is upregulated during fracture healing, although its importance is unclear. Our goal was to assess the functional importance of Hh signaling in endochondral fracture healing. We created closed, transverse diaphyseal femur fractures in mice, stabilized with an intramedullary pin, and administered a systemic Hh inhibitor or vehicle. Because Hh pathway activation is mediated by the receptor Smoothened (Smo), we used the Smo antagonist GDC-0449 (GDC, 50mg/kg, twice daily) to target the pathway. First, in vehicle-treated 10-wk. female C57BL/6 mice we confirmed that Hh signaling was increased in fracture callus compared to intact bone, with >5-fold upregulation of target genes Ptch1 and Gli1. Additionally, using 10-wk. male and female Gli1 reporter mice, we saw a strong activation of the reporter in the osseous regions of the fracture callus 7-10days after fracture. GDC treatment significantly blunted these responses, indicating effective inhibition of fracture-induced Hh signaling in bone. Moreover, microCT analysis revealed that GDC treatment significantly reduced cancellous and cortical bone volume at non-fracture sites (tibial metaphysis and diaphysis), suggesting that the drug inhibited normal bone formation. GDC treatment had a modest effect on fracture healing, with evidence of delayed callus mineralization radiographically (significantly lower Goldberg score at day 14) and by microCT (reduced callus vBMD at 14days), and a delay in the recovery of torsional rotation to normal (elevated rotation-at-peak torque at 21days). On the other hand, GDC treatment did not inhibit qPCR or morphological measures of chondrogenesis or angiogenesis, and did not impair the recovery of failure torque (at day 14 or 21), a measure of biomechanical competence. In summary, GDC treatment inhibited Hh signaling, which delayed but did not prevent fracture healing in young mice. We conclude that Hh signaling is strongly induced after fracture and may play a role in early callus mineralization, although it does not appear to be required for eventual healing.

Abstract

To determine whether the position of the medial clamp tine during syndesmotic reduction affected reduction accuracy.Prospective cohort.Urban Level 1 trauma center.Seventy-two patients with operatively treated syndesmotic injuries.Patients underwent operative fixation of their ankle syndesmotic injuries using reduction forceps. The position of the medial clamp tine was then recorded with intraoperative fluoroscopy. Malreduction rates were then assessed with bilateral ankle computerized tomography.Fibular position within the incisura was measured with respect to the uninjured side to determine whether a malreduction had occurred. Malreductions were then analyzed for associations with injury pattern, patient demographics, and the location of the medial clamp tine.A statistically significant association was found between medial clamp position and sagittal plane syndesmosis malreduction. In reference to anterior fibular translation, there was a 0% malreduction rate in the 18 patients where the clamp tine was placed in the anterior third, a 19.4% malreduction rate in the middle third, and 60% malreduction rate in the posterior third (P = 0.006). In reference to posterior fibular translation, there was a 11.1% malreduction when clamp placement was in the anterior third, a 16.1% malreduction rate in the middle third, and 60% malreduction rate in the posterior third (P = 0.062). There were no significant associations between medial clamp position and coronal plane malreductions (overcompression or undercompression) (P = 1).When using reduction forceps for syndesmotic reduction, the position of the medial clamp tine can be highly variable. The angle created with off-axis syndesmotic clamping is likely a major culprit in iatrogenic malreduction. Sagittal plane malreduction appears to be highly sensitive to clamp obliquity, which is directly related to the medial clamp tine placement. Based on these data, we recommend placing the medial clamp tine in the anterior third of the tibial line on the lateral view to minimize malreduction risk.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Abstract

Scleraxis (Scx) is a known regulator of tendon development, and recent work has identified the role of Scx in bone modeling. However, the role of Scx in fracture healing has not yet been explored. This study was conducted to identify the role of Scx in cortical bone development and fracture healing. Scx green fluorescent protein-labeled (ScxGFP) reporter and Scx-knockout (Scx-mutant) mice were used to assess bone morphometry and the effects of fracture healing on Scx localization and gene expression, as well as callus healing response. Botulinum toxin (BTX) was used to investigate muscle unloading effects on callus shape. Scx-mutant long bones had structural and mechanical defects. Scx gene expression was elevated and bmp4 was decreased at 24 h after fracture. ScxGFP(+) cells were localized throughout the healing callus after fracture. Scx-mutant mice demonstrated disrupted callus healing and asymmetry. Asymmetry of Scx-mutant callus was not due to muscle unloading. Wild-type littermates (age matched) served as controls. This is the first study to explore the role of Scx in cortical bone mechanics and fracture healing. Deletion of Scx during development led to altered long bone properties and callus healing. This study also demonstrated that Scx may play a role in the periosteal response during fracture healing.-McKenzie, J. A., Buettmann, E., Abraham, A. C., Gardner, M. J., Silva, M. J., Killian, M. L. Loss of scleraxis in mice leads to geometric and structural changes in cortical bone, as well as asymmetry in fracture healing.

Abstract

Ankle fractures associated with syndesmotic injury have a poorer prognosis than those without such an injury. Anatomic reduction of the distal tibiofibular joint restores joint congruency and minimizes contact pressures, yet operative fixation of syndesmotic ankle injuries is frequently complicated by malreduction of the syndesmosis. Current methods of assessing reduction have been shown to be inadequate. As such, additional methods to judge the accuracy of syndesmotic reduction are required.The purposes of our study were (1) to determine the anatomic axis of the syndesmosis, or the trans-syndesmotic angle (TSA), and (2) to describe the intraoperative fluoroscopic appearance of syndesmotic clamp reduction oriented along the anatomic syndesmotic angle.Computed tomography (CT) scans of 45 uninjured adult ankles were analyzed to measure the TSA, defined as the angle between the plane of a lateral ankle radiograph and a line drawn perpendicular to the fibular incisura. Three-dimensional reconstructions of CT scans were then used to demonstrate clamp placement collinear with the TSA as would be seen on an intraoperative lateral ankle radiograph.The average TSA measured 215 anterior to the plane of a lateral radiograph. When a simulated reduction clamp tine was placed on the fibular ridge and the clamp oriented along the TSA, the medial tine, as seen on a lateral radiograph, was within the anterior one-third of the tibia 93% of the time. It was, on average, 237% of the distance from the anterior to the posterior tibial cortex, with tine placement occurring in this range in 73% of ankles. The medial tine rested 5317% of the distance between the anterior cortices of the tibia and fibula, with 71% of tines placed in this range.Reduction clamp placement oriented along the TSA has a predictable appearance on lateral ankle imaging and can guide clamp positioning during syndesmotic reduction. With one tine placed on the fibular ridge, placing the medial clamp tine in the anterior third of the tibia, or halfway between the anterior cortices of the tibia and fibula is the most accurate position for reduction in line with the TSA.2 (Retrospective diagnostic).

Abstract

To quantify the incidence of lumbopelvic instability in the setting of unilateral and bilateral sacral fractures and assess whether the presence of bilateral sacral fractures on axial imaging is a useful screening test for lumbopelvic instability.Retrospective case series.Level I trauma center at an academic medical center.A hospital database was used to identify patients diagnosed with a sacral fracture by The International Classification of Diseases, Ninth Revision (ICD-9) code from 2000 to 2014.Axial cross-sectional imaging was reviewed to confirm the presence of unilateral or bilateral sacral ala fractures. Sagittal reconstructions were scrutinized for a transverse fracture line separating the lumbar spine from the pelvis, which was used to define lumbopelvic instability.The Roy-Camille classification system was applied to all identified cases of lumbopelvic instability.One thousand five hundred twenty-six patients were diagnosed with sacral fractures by the ICD-9 code. Four hundred ninety had adequate axial and sagittal cross-sectional imaging. Four hundred forty-three of these patients had unilateral sacral ala fractures, and none of these were associated with lumbopelvic instability. Forty-seven patients had bilateral sacral ala fractures, and 41 of these (87%) had a transverse component indicating some degree of lumbopelvic instability. The presence of bilateral sacral fractures was 100% sensitive and 99% specific for lumbopelvic instability. Among fractures with lumbopelvic instability, 27 (66%) were Roy-Camille type 1, 11 (27%) were type 2, and 3 (7%) were type 3.Bilateral sacral ala fractures are strongly associated with lumbopelvic instability and can be used as a very sensitive and specific screening tool. All patients with bilateral sacral fractures on axial computed tomography or magnetic resonance imaging should have close assessment of the sagittal plane images to evaluate for this pathology.Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Abstract

Patellar tendon ruptures commonly are repaired using transosseous patellar drill tunnels with modified-Krackow sutures in the patellar tendon. This simple suture technique has been associated with failure rates and poor clinical outcomes in a modest proportion of patients. Failure of this repair technique can result from gap formation during loading or a single catastrophic event. Several augmentation techniques have been described to improve the integrity of the repair, but standardized biomechanical evaluation of repair strength among different techniques is lacking.The purpose of this study was to describe a novel figure-of-eight suture technique to augment traditional fixation and evaluate its biomechanical performance. We hypothesized that the augmentation technique would (1) reduce gap formation during cyclic loading and (2) increase the maximum load to failure.Ten pairs (two male, eight female) of fresh-frozen cadaveric knees free of overt disorders or patellar tendon damage were used (average donor age, 76 years; range, 65-87 years). For each pair, one specimen underwent the standard transosseous tunnel suture repair with a modified-Krackow suture technique and the second underwent the standard repair with our experimental augmentation method. Nine pairs were suitable for testing. Each specimen underwent cyclic loading while continuously measuring gap formation across the repair. At the completion of cyclic loading, load to failure testing was performed.A difference in gap formation and mean load to failure was seen in favor of the augmentation technique. At 250 cycles, a 68% increase in gap formation was seen for the control group (control: 5.96 0.86 mm [95% CI, 5.30-6.62 mm]; augmentation: 3.55 0.56 mm [95% CI, 3.12-3.98 mm]; p = 0.02). The mean load to failure was 13% greater in the augmentation group (control: 899.57 96.94 N [95% CI, 825.06-974.09 N]; augmentation: 1030.70 122.41 N [95% CI, 936.61-1124.79 N]; p = 0.01).This biomechanical study showed improved performance of a novel augmentation technique compared with the standard repair, in terms of reduced gap formation during cyclic loading and increased maximum load to failure.Decreased gap formation and higher load to failure may improve healing potential and minimize failure risk. This study shows a potential biomechanical advantage of the augmentation technique, providing support for future clinical investigations comparing this technique with other repair methods that are in common use such as transosseous suture repair.

Abstract

There has recently been an increase in the number of fellowship trained orthopaedic trauma surgeons, raising concerns that the surgical experience of early career surgeons may be diluted. We sought to evaluate the change in complex trauma case volume of orthopaedic trauma surgeons sitting for Part II of the American Board of Orthopaedic Surgeons certification examination.The case log data from all surgeons taking Part II of the American Board of Orthopaedic Surgeons examination over a 13-year period (2003-2015) was evaluated. Any surgeon who examined in the trauma subspecialty was included. We defined pelvis, acetabulum, and periarticular fracture surgeries as complex trauma procedures and evaluated changes in case volume over time.We included 468 candidates who examined as trauma subspecialists and performed 90,261 procedures. The number of candidates testing in trauma per year ranged from 15 to 65 and increased significantly over time [ = 4.05 (0.37), P < 0.0001]. Their case volume was stable over time [ = -1.7 (1.1), P = 0.16]. The number of acetabulum fracture surgeries performed decreased significantly over time from a mean of 10.1 cases in 2003 to 5.2 cases in 2015 [ = -0.34 (0.08), P = 0.0015]. There was no significant change in the number of pelvic fracture surgeries [ = -0.1 (0.1), P = 0.285]. There was a trend toward less periarticular fracture surgeries [ = -0.3 (0.1), P = 0.072].Although pelvic ring and periarticular fracture case volume have remained stable, early career surgeons have experienced a significant decrease in acetabular fracture case volume. The implications of this decreased surgical experience warrant careful consideration as the orthopaedic trauma workforce evolves.

Abstract

Stress modulation is the concept of manipulating bridge plate variables to provide a flexible fixation construct that allows callus formation through uneventful secondary bone healing. Obtaining absolute stability through the anatomic reduction of all fracture fragments comes at the expense of fracture biology, whereas intramedullary nailing, which is more advantageous for diaphyseal fractures of the lower extremity, is technically demanding and often may not be possible when stabilizing many metaphyseal fractures. Overly stiff plating constructs are associated with asymmetric callus formation, early implant failure, and fracture nonunion. Numerous surgeon-controlled variables can be manipulated to increase flexibility without sacrificing strength, including using longer plates with well-spaced screws, choosing titanium or stainless steel implants, and using locking or nonlocking screws. Axially dynamic emerging concepts, such as far cortical locking and near cortical overdrilling, provide further treatment options when bridge plating techniques are used.

Abstract

Several approaches to the proximal humerus for fracture fixation are possible. The traditional utilitarian approach to the shoulder, the deltopectoral, has distinct disadvantages when performing fracture reduction and locked plating. The anterolateral acromial approach exploits the intermuscular plane between the anterior and middle heads of the deltoid. After identifying the position of the axillary nerve as it crosses this interval, fracture reduction and fixation is performed. Direct access to both the greater and the lesser tuberosities is facilitated. The cancellous surface of the humeral head fragment provides an excellent surface for direct manipulation without further endangering the extraosseous soft tissue attachments.

Abstract

The distal tibiofibular syndesmosis is disrupted in up to 45% of operatively treated ankle fractures, and syndesmotic malreduction has historically been correlated with poor outcome. The purpose of this study was to quantify the clamp force used during syndesmotic reduction and to evaluate the effect of clamp force on fibular overmedialization (overcompression) at the level of the distal tibiofibular syndesmosis.A prospectively recruited cohort of 21 patients underwent operative syndesmotic reduction and fixation. A ball point periarticular reduction forceps that was modified to include a load cell in one tine was used for the reduction, and the clamp force required for reduction was measured. Patients underwent postoperative bilateral computed tomographic scans of the ankle and hindfoot to assess syndesmotic reduction. The uninjured extremity was used as a control. Side-to-side differences in fibular medialization, translation, and rotation within the tibial incisura were measured. These findings were correlated with the reduction clamp force utilized to obtain the reduction.Syndesmotic overcompression (fibular medialization greater than 1.0 mm when compared with noninjured ankle) was seen in 11 of 21 patients (52%). Increased clamp force significantly correlated with syndesmotic overcompression. The mean reduction clamp forces were 88 N for the undercompressed group, 130 N for the adequately compressed group, and 163 N for the overcompressed group.This study demonstrated a significant correlation between increased clamp forces and syndesmotic overcompression, and determined objective forces that lead to overcompression. Our results indicate that surgeons should be cognizant of the clamp force used for syndesmotic reduction.Level III, case-control series, in accordance with STROBE guidelines.

Abstract

The goal of this study was to objectively assess if rotational or translational syndesmotic malreduction is associated with certain syndesmotic morphologies. Prior studies based on subjective assessment of syndesmotic morphology and reduction have not shown any difference between groups.Thirty-five prospectively recruited patients with operatively treated syndesmotic injuries were recruited at an Urban Level I Trauma Center. Patients underwent postoperative bilateral computed tomographic (CT) scans of the ankle to assess incisura depth and syndesmotic reduction. The uninjured extremity was used as a control. Side-to-side differences of syndesmotic reduction were measured at several anatomic points and compared to the incisura depth.There was a significant correlation between more shallow syndesmoses and increased anterior translation of the fibula in the incisura (r = -0.63, P .001). Six of 8 patients with "shallow" (2.5 mm) incisura were anteriorly malreduced greater than or equal to 1.5 mm compared to the contralateral ankle. The anterior malreduction rate in those with a shallow incisura was significantly greater than in the "non-shallow" patients (P < .001). There were 9 patients with incisurae greater than or equal to 4.5 mm deep. Five of the "deep" patients had posterior malreductions greater than or equal to 1.5 mm. The posterior malreduction rate in the "deep" group was significantly greater than the "non-deep" patients (P = .02). There was a significant correlation between increasing syndesmotic depth and increased malrotation (r = .46, P = .01).Syndesmotic morphology was found to be associated with specific malreduction patterns. Shallow syndesmoses were correlated with anterior fibular malreduction, and were less likely to be malrotated. Conversely, deep syndesmoses predisposed to posterior sagittal plane and rotational malalignment. Preoperative CT scans that assess the syndesmosis morphology may allow surgeons to alter reduction strategies to avoid syndesmotic malreduction.Level III, retrospective cohort study.

Abstract

Osteoporotic fractures are difficult to manage. They pose a number of difficulties to the surgeon arising from the underlying poor bone stock compromising the intention to achieve optimum fixation. Moreover, the frail elderly patients present with a variety of medical co-morbidities increasing the risk of developing perioperative complications. Despite these recognized challenges, there are currently a number of improving technologies and strategies at the surgeon's disposal to provide more confidence with fracture fixation and maximize the chance of success.

Abstract

Scant evidence exists to support antibiotic use for low velocity ballistic fractures (LVBF). We therefore sought to define current practice patterns. We hypothesized that most surgeons prescribe antibiotics for LVBF, prescribing is not driven by institutional protocols, and that decisions are based on protocols utilized for blunt trauma.A web-based questionnaire was emailed to the membership of the Orthopaedic Trauma Association (OTA). The questionnaire included demographic information and questions about LVBF treatment practices. Two hundred and twenty surgeons responded. One hundred and fifty-four (70%) respondents worked at a Level-1 trauma center, 176 (80%) had received fellowship education in orthopaedic trauma and 104 (47%) treated at least 10 ballistic fractures annually. Responses were analyzed with SAS 9.3 for Windows (SAS Institute Inc, Cary, NC).One hundred eighty-six respondents (86%) routinely provide antibiotics for LVBF. Those who did not were more apt to do so for intra-articular fractures (8/16, 50%) and pelvic fractures with visceral injury (10/16, 63%). Most surgeons (167, 76%) do not believe the Gustilo-Anderson classification applies to ballistic fractures, and (20/29, 70%) do not base their antibiotic choice on the classification system. Few institutions (58, 26%) have protocols guiding antibiotic use for LVBF.Routine antibiotic use for LVBF is common; however, practice is not dictated by institutional protocol. Although antibiotic use generally follows current blunt trauma guidelines, surgeons do not base their treatment decisions the Gustilo-Anderson classification. Given the high rate of antibiotic use for LVBF, further study should focus on providing evidence-based treatment guidelines.

Abstract

Post-operative knee pain is common following intramedullary nailing of the tibia, regardless of surgical approach, though the exact source is controversial. Historically, the most common surgical approaches position the knee in hyperflexion, including patellar tendon splitting (PTS) and medial parapatellar (MPP). A novel technique, the semi-extended lateral parapatellar approach simplifies patient positioning, fracture reduction, fluoroscopic assessment, and implant insertion. It also avoids violation of the knee joint capsule. However, this approach has not yet been directly compared against the historical standards. We hypothesised that in a comparison of patient outcomes, the semi-extended approach would be associated with decreased knee pain and better function relative to knee hyperflexion approaches.A trauma patient database from a Level I centre was queried for patients who underwent intramedullary nailing of the tibia between 2009 and 2013. Patients were surveyed for knee pain severity (NRS scale 1 to 10) and location, and completion of the Lysholm Knee Scale (LKS). Data was compared between the semi-extended lateral parapatellar, medial parapatellar, and tendon splitting groups regarding knee pain severity, location, total LKS, and individual knee function scores from the Lysholm questionnaire. Pre-hoc power analysis determined the necessary sample size (n=34). Post-hoc analysis utilised two-way ANOVA analysis with a significance threshold of p<0.05.Comparison of knee pain severity between the groups found no significant difference (p=0.69), with average ratings of: semi-extended (3.26), PTS (3.59), and MPP (3.63). Analysis found no significant differences in total LKS score (p=0.33), with average sums of: semi-extended (75.97), MPP (77.53), and PTS (81.68). Individual knee function scores from the LKS were similar between the groups, except for limping, with MPP being significantly worse (p=0.04). There was no significant difference in knee pain location (p=0.45).In this adequately-powered study, at minimum 1 year follow-up there were no significant differences between the 3 approaches in knee pain severity, location, or overall function. The three were significantly different in post-operative limping, with medial parapatellar having the lowest score. The semi-extended lateral parapatellar approach vastly simplifies many technical aspects of nailing compared to knee hyperflexion approaches, and does not violate the knee joint.

Abstract

To determine current practice standards among Orthopaedic Trauma Association surgeons for postoperative fracture follow-up and to investigate the implications of these standards on clinical research.Survey.Web-based survey.One hundred eighty-four orthopaedic trauma surgeons.A web-based questionnaire was distributed to Orthopaedic Trauma Association members to identify standard postoperative radiographic and clinical follow-up duration. Assuming uneventful, complete fracture healing at 3 months, data were collected for 3 generic fracture types (diaphyseal, extra-articular metaphyseal, and intra-articular) and 3 specific fractures (femoral shaft, intertrochanteric, and tibial plateau). Suggested follow-up for clinical research was also investigated.For extra-articular fractures, standard radiographic and clinical follow-up were considered to be 6 months or less by greater than 70% of respondents. For intra-articular fractures, standard radiographic and clinical follow-up was considered to be 6 months or less by greater than 39% of respondents. The most common responses for radiographic follow-up were 3 months for extra-articular fractures (33%) and 12 months for intra-articular fractures (34%). The most common responses for clinical follow-up were 6 months for extra-articular fractures (37%) and 12 months for intra-articular fractures (35%). The majority (55%) indicated that follow-up to clinical and radiographic healing or the establishment of a nonunion should be the minimum follow-up for clinical fracture studies and 66% recommended follow-up to at least 1 year for functional outcome studies.Most surgeons follow-up patients with lower extremity extra-articular fractures (with uneventful healing) radiographically for 3-6 months and clinically for 6 months and slightly longer for intra-articular fractures. Many surgeons cease radiographic and clinical follow-up by 6 months. Therefore, retrospective fracture healing studies can only reasonably expect follow-up for 6 months. Publication requirements for longer follow-up of fracture-related studies would likely eliminated retrospective studies from consideration. Most surgeons support obtaining at least 1-year follow-up for clinical studies that include functional outcome.Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Abstract

There has recently been an increase in the number of fellowship trained orthopaedic trauma surgeons, raising concerns that the surgical experience of early career surgeons may be diluted. We sought to evaluate the change in complex trauma case volume of orthopaedic trauma surgeons sitting for Part II of the American Board of Orthopaedic Surgeons certification examination.The case log data from all surgeons taking Part II of the American Board of Orthopaedic Surgeons examination over a 13-year period (2003-2015) was evaluated. Any surgeon who examined in the trauma subspecialty was included. We defined pelvis, acetabulum, and periarticular fracture surgeries as complex trauma procedures and evaluated changes in case volume over time.We included 468 candidates who examined as trauma subspecialists and performed 90,261 procedures. The number of candidates testing in trauma per year ranged from 15 to 65 and increased significantly over time [ = 4.05 (0.37), P < 0.0001]. Their case volume was stable over time [ = -1.7 (1.1), P = 0.16]. The number of acetabulum fracture surgeries performed decreased significantly over time from a mean of 10.1 cases in 2003 to 5.2 cases in 2015 [ = -0.34 (0.08), P = 0.0015]. There was no significant change in the number of pelvic fracture surgeries [ = -0.1 (0.1), P = 0.285]. There was a trend toward less periarticular fracture surgeries [ = -0.3 (0.1), P = 0.072].Although pelvic ring and periarticular fracture case volume have remained stable, early career surgeons have experienced a significant decrease in acetabular fracture case volume. The implications of this decreased surgical experience warrant careful consideration as the orthopaedic trauma workforce evolves.

Abstract

Post-natal osteogenesis after mechanical trauma or stimulus occurs through either endochondral healing, intramembranous healing or lamellar bone formation. Bone morphogenetic protein 2 (BMP2) is up-regulated in each of these osteogenic processes and is expressed by a variety of cells including osteoblasts and vascular cells. It is known that genetic knockout of Bmp2 in all cells or in osteo-chondroprogenitor cells completely abrogates endochondral healing after full fracture. However, the importance of BMP2 from differentiated osteoblasts and endothelial cells is not known. Moreover, the importance of BMP2 in non-endochondral bone formation such as intramembranous healing or lamellar bone formation is not known. Using inducible and tissue-specific Cre-lox mediated targeting of Bmp2 in adult (10-24 week old) mice, we assessed the role of BMP2 expression globally, by osteoblasts, and by vascular endothelial cells in endochondral healing, intramembranous healing and lamellar bone formation. These three osteogenic processes were modeled using full femur fracture, ulnar stress fracture, and ulnar non-damaging cyclic loading, respectively. Our results confirmed the requirement of BMP2 for endochondral fracture healing, as mice in which Bmp2 was knocked out in all cells prior to fracture failed to form a callus. Targeted deletion of Bmp2 in osteoblasts (osterix-expressing) or vascular endothelial cells (vascular endothelial cadherin-expressing) did not impact fracture healing in any way. Regarding non-endochondral bone formation, we found that BMP2 is largely dispensable for intramembranous bone formation after stress fracture and also not required for lamellar bone formation induced by mechanical loading. Taken together our results indicate that osteoblasts and endothelial cells are not a critical source of BMP2 in endochondral fracture healing, and that non-endochondral bone formation in the adult mouse is not as critically dependent on BMP2.

Abstract

While there is conflicting evidence regarding the importance of anatomic reduction for tibial plateau fractures, there are currently no studies that analyse our ability to grade reduction based on fluoroscopic imaging. The purpose of this study was to determine the accuracy of fluoroscopy in judging tibial plateau articular reduction.Ten embalmed human cadavers were selected. The lateral plateau was sagitally sectioned, and the joint was reduced under direct visualization. Lateral, anterior-posterior (AP), and joint line fluoroscopic views were obtained. The same fluoroscopic views were obtained with 2mm displacement and 5mm displacement. The images were randomised, and eight orthopaedic traumatologists were asked whether the plateau was reduced. Within each pair of conditions (view and displacement from 0mm to 5mm) sensitivity, specificity, and intraclass correlations (ICC) were evaluated.The AP-lateral view with 5mm displacement yielded the highest accuracy for detecting reduction at 90% (95% CI: 83-94%). For the other conditions, accuracy ranged from (37-83%). Sensitivity was highest for the reduced lateral view (79%, 95% CI: 57-91%). Specificity was highest in the AP-lateral view 98% (95% CI: 93-99%) for 5mm step-off. ICC was perfect for the AP-lateral view with 5mm displacement, but otherwise agreement ranged from poor to moderate at ICC=0.09-0.46. Finally, there was no additional benefit to including the joint-line view with the AP and lateral views.Using both AP and lateral views for 5mm displacement had the highest accuracy, specificity, and ICC. Outside of this scenario, agreement was poor to moderate and accuracy was low. Applying this clinically, direct visualization of the articular surface may be necessary to ensure malreduction less than 5mm.

Abstract

Nonunion after locked bridge plating of comminuted distal femur fractures is not uncommon. "Dynamic" locked plating may create an improved mechanical environment, thereby achieving higher union rates than standard locked plating constructs.Academic Level 1 Trauma Center.Twenty-eight patients with comminuted supracondylar femur fractures treated with either dynamic or standard locked plating.Dynamic plating was achieved using an overdrilling technique of the near cortex to allow for a 0.5-mm "halo" around the screw shaft at the near cortex. Standard locked plating was done based on manufacturer's suggested technique. The patients treated with dynamic plating were matched 1:1 with those treated with standard locked plating based on OTA classification and working length.Three blinded observers made callus measurements on 6-week radiographs using a 4-point ordinal scale. The results were analyzed using a 2-tailed t test and 2-way intraclass correlations.The dynamic plating group had significantly greater callus (2.0; SD, 0.7) compared with the control group (1.3: SD, 0.8, P = 0.048) with substantial agreement amongst observers in both consistency (0.724) and absolute score (0.734). With dynamic plating group, 1 patient failed to unite, versus three in the control group (P = 0.59). The dynamic group had a mean change in coronal plane alignment of 0.5 degrees (SD, 2.6) compared with 0.6 (SD, 3.0) for the control group (P = 0.9) without fixation failure in either group.Overdrilling the near cortex in metaphyseal bridge plating can be adapted to standard implants to create a dynamic construct and increase axial motion. This technique seems to be safe and leads to increased callus formation, which may decrease nonunion rates seen with standard locked plating.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Abstract

The goals of this study were to assess syndesmotic reductions using computerized tomography and to determine whether malreductions are associated with certain injury types or reduction forceps.Prospective cohort.Urban level 1 trauma center.Twenty-seven patients with operatively treated syndesmotic injuries were recruited prospectively.Patients underwent postoperative bilateral computerized tomography of the ankle and hindfoot to assess syndesmotic reduction. The uninjured extremity was used as a control.Side-to-side differences of the fibular position within the tibial incisura were measured at several anatomic points and analyzed based on injury type, the presence of posterior malleolar injury, level of fracture, and type of reduction forceps used.On average, operatively treated syndesmotic injuries were overcompressed (fibular medialization) by 1 mm (P < 0.001) and externally rotated by 5 (P = 0.002) when compared with the uninjured extremity. The absence of a posterior malleolar injury and Weber B (OTA 44-B) fractures seemed to have a protective effect against malrotation, but not against overcompression. There was no difference in malreduction based on the type of the clamp used.It is possible, and highly likely based on these data, to overcompress the syndesmosis when using reduction forceps. Care should be taken to avoid overcompression, as this may affect the ankle motion and functional outcomes. To our knowledge, this is the first in vivo series of syndesmotic overcompression.Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Abstract

Malleolar ankle fractures associated with syndesmotic injuries are common. Diagnosis of the syndesmotic injury can be difficult and often requires intraoperative fluoroscopic stress testing. Accurate reduction and stable fixation of the syndesmosis are critical to maximize patient outcomes. Recent literature has demonstrated that the unstable syndesmosis is particularly prone to iatrogenic malreduction. Multiple types of malreduction can occur, including translational, rotational, and overcompression. Knowledge of the technical details regarding intraoperative reduction methods and reduction assessment can minimize the risk of syndesmotic malreduction and improve patient outcomes.

Abstract

ASXL2 is an ETP family protein that interacts with PPAR. We find that ASXL2-/- mice are insulin resistant, lipodystrophic, and fail to respond to a high-fat diet. Consistent with genetic variation at the ASXL2 locus and human bone mineral density, ASXL2-/- mice are also severely osteopetrotic because of failed osteoclast differentiation attended by normal bone formation. ASXL2 regulates the osteoclast via two distinct signaling pathways. It induces osteoclast formation in a PPAR/c-Fos-dependent manner and is required for RANK ligand- and thiazolidinedione-induced bone resorption independent of PGC-1. ASXL2 also promotes osteoclast mitochondrial biogenesis in a process mediated by PGC-1 but independent of c-Fos. Thus, ASXL2 is a master regulator of skeletal, lipid, and glucose homeostasis.

Abstract

The purpose of this study was to determine factors, including day of week of hospital admission, associated with delay to surgery (DTS) and increased length of stay (LOS) in patients with hip fractures.Retrospective.Level I Trauma Center.Six hundred thirty-five consecutive patients admitted to a single hospital between January 1999 and July 2006 aged 65 years or older with a hip fracture (OTA 31) were identified retrospectively from an orthopaedic database. Demographic data, American Society of Anesthesiologists (ASA) score, hospital admission and discharge dates, the date of surgery, and details of any preoperative cardiac testing were extracted from the hospital record. These data were used to identify the day of week for hospital admission and to calculate days for DTS and hospital LOS. Linear regression was used to identify independent variables associated with DTS and increased LOS.All patients underwent surgical treatment of a hip fracture (OTA 31).Factors affecting DTS and LOS.Independent factors associated with DTS included the day of week for hospital admission, ASA score, and the need for preoperative cardiac testing. Patients admitted Thursday through Saturday had longer DTS (mean, 2.2-2.7 days) than did patients admitted other days (mean, 1.7-1.8). DTS increased for increasing ASA: 1.4 days for ASA 2, 2.0 days for ASA 3, and 3.0 days for ASA 4. Those requiring preoperative cardiac testing had an increased number of days to surgery (mean, 3.2 days) than those without (mean, 1.7 days). Independent factors associated with increasing hospital LOS included ASA, the need for preoperative cardiac testing, male gender, and day of admission. LOS increased for increasing ASA: 6.3 days for ASA 2, 8.1 days for ASA 3, and 10.1 days for ASA 4. Those requiring preoperative cardiac testing had an increased LOS (mean, 9.4 days) than those without (mean, 7.3 days). Male patients had a longer LOS (mean, 9.8 days) than did females (mean, 7.3 days). Patients admitted on Thursday or Friday (mean, 8.5-9.1 days) had longer LOS than those admitted on other days (mean, 7.3-7.9 days).This is the first study to consider and identify the day of admission and need for preoperative cardiac tests as determinants of DTS and LOS for geriatric patients with hip fracture. Relative scarcity of weekend hospital resources, when present, may be responsible for these delays. This study also confirms that patient medical condition as measured by ASA affects both DTS and LOS.Prognostic level II. See Instructions for Authors for a complete description of levels of evidence.

Abstract

To determine if distal femoral traction pins result in knee dysfunction in patients with femoral or pelvic fracture, and to determine if skeletal traction relieves pain more effectively than splinting for femoral shaft fractures.Prospective cohort trial.Level I urban trauma center.One hundred twenty adult patients with femoral shaft, acetabular, and unstable pelvic fractures.Patients with femoral shaft fractures were placed into distal femoral skeletal traction or a long-leg splint, based on an attending-specific protocol. Patients with pelvic or acetabular fractures with instability or intraarticular bone fragments were placed into skeletal traction.An initial Lysholm knee survey was administered to assess preinjury knee pain and function; the survey was repeated at 3- and 6-month follow-up visits. Also, a 10-point visual analog scale was used to document pain immediately before, during, and immediately after fracture immobilization with traction or splinting.Thirty-five patients (29%) were immobilized with a long-leg splint, and 85 (71%) were immobilized with a distal femoral traction pin. Eighty-four patients (70%) completed a 6-month follow-up. Lysholm scores decreased by a mean 9.3 points from preinjury baseline to 6 months postinjury in the entire cohort (P < 0.01); no significant differences were found between the splint and traction pin groups. During application of immobilization, visual analog scale pain scores were significantly lower in traction patients as compared with splinted patients (mean, 1.9 points less, P < 0.01). Traction pins caused no infections, neurovascular injuries, or iatrogenic fractures.Distal femoral skeletal traction does not result in detectable knee dysfunction at 6 months after insertion, and results in less pain during and after immobilization than long-leg splinting.Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Abstract

Surgeons' disagreement about ideal treatment for proximal humerus fractures (PHFs) may reflect a difference in training. We conducted a study to compare treatment decision-making by experienced shoulder and trauma fellowship--trained surgeons. Two expert shoulder surgeons and 2 expert trauma surgeons reviewed 100 consecutive PHFs surgically treated at another institution. Using available imaging, the examiners assigned scores for agreement with treatment decisions and for ratings of reduction/arthroplasty placement, fixation method, and radiographic outcomes. The scores were evaluated for interobserver reliability using intraclass correlation coefficients. Overall, these experienced surgeons agreed poorly with treatment decisions and fixation methods but agreed moderately on acceptable reductions/arthroplasty placement and final radiographic outcomes. Agreement on the final radiographic outcomes was more uniform and acceptable for both shoulder and trauma surgeons. Trauma surgeons agreed more with each other about treatment decisions than shoulder surgeons agreed with each other. In this study, surgeon disagreement and an aging population highlight the need for better evidence regarding optimal treatment for PHFs in order to improve consensus.

Abstract

Tibial shaft fractures distal to total knee arthroplasty are rare, but they are likely to become more common with the increasing number of arthroplasty procedures being performed. These fracture patterns have been treated in the past either with closed reduction and casting/bracing or with open reduction internal fixation using plates. Weight-bearing precautions in the elderly patient population can affect patient disposition, and weight bearing on extramedullary fixation can lead to early hardware failure. We present a series of nailing techniques that can be used for tibial fractures distal to a well-fixed total knee arthroplasty that avoids the tibial baseplate, provides stable fracture fixation, and allows for early weight bearing.

Abstract

The null hypothesis of this study states that routine axial computed tomography (CT) images are obtained at a consistent and reproducible orientation relative to the sacrum. The secondary null hypothesis states that there is no difference in the measurement of the safe zone for placement of iliosacral screws when using routine axial CT images and standardized reconstructions in defined planes perpendicular and parallel to the sacrum.Retrospective review.University Level 1 Trauma Center.Sixty-eight consecutive trauma patients evaluated with routine pelvic CT, without pelvic ring injury.Retrospective radiographic review and measurement.Sixty-eight consecutive adult patients with routine axial pelvic CT scans, without injury to the pelvic ring, and obtained as part of a trauma evaluation were retrospectively identified. The orientation of the axial slices relative to the sacrum was measured for each patient and compared. The maximal cross-sectional distance at the smallest section of the sacral ala (safe zone) was measured using the routine axial CT images, and these measurements were compared with similar measurements taken on standardized images perpendicular (CT inlet) and parallel (CT outlet) to the body of the sacrum. Additional data referencing the orientation of multiple sacral radiographic landmarks were also collected.The orientation of routine axial CT image planes relative to the sacrum spanned a wide range. The angle between the routine axial CT plane and the sacrum varied from 43.5 to 82.0 degrees (SD = 9 degrees). Significant differences were found in measured safe zones of routine axial CT images compared with standardized CT inlet and CT outlet images. Compared with CT inlet images, routine axial CT images underestimated safe zones for transverse sacral screws at both S1 (P < 0.01) and S2 (P < 0.01). When compared with CT outlet images, routine axial CT images overestimated safe zones for oblique sacroiliac screws (P < 0.01) and underestimated the safe zone for S2 transverse sacral style screws (P < 0.01). No significant differences in measured variables were found between genders and sacral morphology.Our null hypotheses were rejected: routine axial CT images were found to be at widely ranging orientations relative to the sacrum, and standardized CT images (CT inlet and CT outlet) demonstrated statistically significant differences in measurements of safe zones compared with routine axial CT images. Furthermore, the CT inlet and CT outlet views provide additional information regarding sacral landmarks that could be useful for preoperative planning.

Abstract

There is increasing evidence associating "atypical" femoral fractures with prolonged exposure to bisphosphonate therapy. The cause of these fractures is unknown and likely multifactorial. This study evaluated the hypothesis that patients with primary osteoporosis who sustain atypical femoral fracture(s) while on chronic bisphosphonate therapy have a more varus proximal femoral geometry than patients who use bisphosphonates for primary osteoporosis but do not sustain a femoral fracture.The femoral neck-shaft angle was measured on the radiographs of 111 patients with atypical femoral shaft fracture(s) and thirty-three asymptomatic patients; both groups were on chronic bisphosphonate therapy. Patients with characteristic lateral cortical thickening, stress lines, and thigh pain were included in the fracture group.The mean neck-shaft angle of the patients who sustained atypical femoral fracture(s) while taking bisphosphonates (case group) differed significantly from that of the patients on bisphosphonate therapy without a fracture (129.5 versus 133.8; p < 0.001). Fifty-three (48%) of the patients in the case group had a neck-shaft angle that was lower than the lowest angle in the control group (128). Side-to-side comparison in patients with a unilateral pathologic involvement and an asymptomatic contralateral lower limb did not demonstrate any significant difference between the neck-shaft angles in the two limbs.Patients on chronic bisphosphonate therapy who presented with atypical femoral fracture(s) had more varus proximal femoral geometry than those who took bisphosphonates without sustaining a fracture. Although no causative effect can be determined, a finding of varus geometry may help to better identify patients at risk for fracture after long-term bisphosphonate use.

Abstract

Total elbow arthroplasty (TEA) is a viable treatment for elderly patients with distal humerus fracture who frequently present with low-grade open fractures. This purpose of this study was to evaluate the results of a protocol of serial irrigations and debridements (I&Ds) followed by primary TEA for the treatment of open intra-articular distal humerus fractures.Seven patients (mean 74 years; range 56-86 years) with open (two Grade I and five Grade 2) distal humerus fractures (OTA 13C) who were treated between 2001 and 2007 with a standard staged protocol that included TEA were studied. Baseline Disabilities of the Arm, Shoulder and Hand (DASH) scores were obtained during the initial hospitalization, and the 6- and 12-month follow-up visits. Elbow range of motion (ROM) measurements were obtained at each follow-up visit.Follow-up averaged 43 (range 4-138) months. There were no wound complications and no deep infections. Complications included one case of heterotopic ossification with joint contracture, one olecranon fracture unrelated to the TEA, and two loose humeral stems. The average final ROM was from 21 (range 5-30) to 113 flexion (range 90-130). DASH scores averaged 25 at pre-injury baseline and 48 at the most recent follow-up visits.TEA has become a mainstream option for the treatment of distal humerus fractures which are on occasion open. There is hesitation in using arthroplasty in an open fracture setting due to a potential increased infection risk. The absence of any infectious complications and satisfactory functional outcomes observed in the current series indicates that TEA is a viable treatment modality for complex open fractures of the distal humerus.

Abstract

To determine whether clavicle fracture displacement and shortening are different between upright and supine radiographic examinations.Combined retrospective and prospective comparative study.Level I Trauma Center.Forty-six patients (mean age, 49 years; range, 24-89 years) with an acute clavicle fracture were evaluated.Standardized clavicle radiographs were obtained in both supine and upright positions for each patient. Displacement and shortening were measured and compared between the 2 positions.One resident and 3 traumatologists classified the fractures and measured displacement and shortening. Data were aggregated and compared to ensure reliability with a 2-way mixed intraclass correlation.Fracture displacement was significantly greater when measured from upright radiographs (15.9 8.9 mm) than from supine radiographs (8.4 6.6 mm, P < 0.001), representing an 89% increase in displacement with upright positioning. Forty-one percent of patients had greater than 100% displacement on upright but not on supine radiographs. Compared with the uninjured side, 3.0 10.7 mm of shortening was noted on upright radiographs and 1.3 9.5 mm of lengthening on supine radiographs (P < 0.001). The intraclass correlation was 0.82 [95% confidence interval (CI), 0.73-0.89] for OTA fracture classification, 0.81 (95% CI, 0.75-0.87) for vertical displacement, and 0.92 (95% CI, 0.88-0.95) for injured clavicle length, demonstrating very high agreement among evaluators.Increased fracture displacement and shortening was observed on upright compared with supine radiographs. This suggests that upright radiographs may better demonstrate clavicle displacement and predict the position at healing if nonoperative treatment is selected.

Abstract

The purpose of this study was to compare the infection risk when internal fixation plates either overlap or did not overlap previous external fixator pin sites in patients with bicondylar tibial plateau fractures and pilon fractures treated with a 2-staged protocol of acute spanning external fixation and later definitive internal fixation.Retrospective comparison study.Two level I trauma centers.A total of 85 OTA 41C bicondylar tibial plateau fractures and 97 OTA 43C pilon fractures treated between 2005 and 2010. Radiographs were evaluated to determine the positions of definitive plates in relation to external fixator pin sites and patients were grouped into an "overlapping" group and a "nonoverlapping" group.Fifty patients had overlapping pin sites and 132 did not.Presence of a deep wound infection.Overall, 25 patients developed a deep wound infection. Of the 50 patients in the "overlapping" group, 12 (24%) developed a deep infection compared with 13 (10%) of the 132 patients in the "nonoverlapping" group (P = 0.033).Placement of definitive plate fixation overlapping previous external fixator pin sites significantly increases the risk of deep infection in the 2-staged treatment of bicondylar tibial plateau and pilon fractures. Surgeons must make a conscious effort to place external fixator pins outside of future definitive fixation sites to reduce the overall incidence of deep wound infections. Additionally, consideration must be given to the relative benefit of a spanning external fixator in light of the potential for infection associated with their use.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Abstract

The evolution of locking plates and modern nail constructs provides the orthopaedic trauma surgeon with a myriad of options with regard to implant selection for common fractures. There is a significant amount of biomechanical literature comparing modern constructs with those conventionally used. A basic understanding of this literature is required to make informed decisions with regard to implant selection in the management of these injuries. This article reviews the most recent biomechanical literature regarding implant selection and application for a variety of commonly treated injuries, including fractures of the clavicle, proximal humerus, distal humerus, intertrochanteric hip region, distal femur, and bicondylar tibial plateau.

Abstract

Locked plating has become a standard method to treat supracondylar femur fractures. Emerging evidence indicates that this method of treatment is associated with modest failure rates. The goals of this study were to determine risk factors for complications and to provide technical recommendations for locked plating of supracondylar femur fractures.Retrospective review.Three level I or II trauma centers.Three hundred twenty-six patients with 335 distal femur fractures (OTA 33A or C, 33% open) treated with lateral locked plates were studied. The average patient age was 57 years (range 17-97 years), 55% were women, 34% were obese, 19% were diabetic, and 24% were smokers.All patients were managed with open reduction internal fixation using a lateral distal femoral locked plate construct that included locked screws in the distal fragment and nonlocked, locked, or a combination of locked and nonlocked screws in the proximal fragment.Risk factors for reoperation to promote union, deep infection, and implant failure.After the index procedure, 64 fractures (19%) required reoperation to promote union, including 30 that had a planned staged bone grafting because of the metaphyseal defect after debridement of an open fracture. Independent risk factors for reoperation to promote union and deep infection included diabetes and open fracture. Risk factors for proximal implant failure included open fracture, smoking, increased body mass index, and shorter plate length.The identified risk factors for reoperation to promote union and complications included open fracture, diabetes, smoking, increased body mass index, and shorter plate length. Most factors are out of surgeon control but are useful when considering prognosis. Use of relatively long plates is a technical factor that can reduce risk for fixation failure.Prognostic level II. See instructions for authors for a complete description of levels of evidence.

Abstract

Successful treatment of bicondylar tibial plateau requires focused and specific assessment and treatment of the medial fragment. Many fragment variations exist that help guide treatment. This may include posteromedial or medial plating using a variety of reduction and fixation techniques, or indirect reduction and lateral locked plating. With appropriate assessment, good results can be achieved.

Abstract

This study compared results of aggressive and nonaggressive debridement protocols for the treatment of high-energy, open supracondylar femur fractures after the primary procedure, with respect to the requirement for secondary bone grafting procedures, and deep infection.Retrospective review.Level I and level II trauma centers.Twenty-nine consecutive patients with high-grade, open (Gustilo types II and III) supracondylar femur fractures (OTA/AO 33A and C) treated with debridement and locked plating.Surgeons at 2 different level I trauma centers had different debridement protocols for open supracondylar femur fractures. One center used a more aggressive (MA) protocol in their patients (n = 17) that included removal of all devitalized bone and placement of antibiotic cement spacers to fill large segmental defects. The other center used a less aggressive (LA) protocol in their patients (n = 12) that included debridement of grossly contaminated bone with retention of other bone fragments and no use of antibiotic cement spacers. All other aspects of the treatment protocol at the 2 centers were similar: definitive fixation with locked plates in all cases, IV antibiotics were used until definitive wound closure, and weight bearing was advanced upon clinical and radiographic evidence of fracture healing.Healing after the primary procedure, requirement for secondary bone grafting procedures, and the presence of deep infection.Demographics were similar between included patients at each center with regard to age, gender, rate of open fractures, open fracture classification, mechanism, and smoking (P > 0.05). Patients at the MA center were more often diabetic (P < 0.05). Cement spacers to fill segmental defects were used more often after MA debridement (35% vs. 0%, P < 0.006), and more patients had a plan for staged bone grafting after MA debridement (71% vs. 8%, P < 0.006). Healing after the index fixation procedure occurred more often after LA debridement (92% vs. 35%, P < 0.003). There was no difference in infection rate between the 2 protocols: 25% with the LA protocol and 18% with the MA protocol (P = 0.63). All patients in both groups eventually healed and were without evidence of infection at an average of 1.8 years of follow-up.The degree to which bone should be debrided after a high-energy, high-grade, open supracondylar femur fracture is a matter of surgeon judgment and falls along a continuous spectrum. Based on the results of the current study, the theoretic trade-off between infection risk and osseous healing potential seems to favor an LA approach toward bone debridement in the initial treatment.Therapeutic level III.

Abstract

The increasing frequency of orthopaedic trauma patient transfers is an issue at the centre of the current orthopaedic "call crisis" that has the potential to inundate resources at tertiary care centres. Appropriateness of transfer has been investigated only from the perspective of receiving surgeons. This study investigates the suitability and reasons for orthopaedic trauma patient transfer from the viewpoint of transferring surgeons.A questionnaire was e-mailed to a random sampling of 500 active members of the American Academy of Orthopaedic Surgeons and the Orthopaedic Trauma Association. Surgeons were split into three groups: senders of trauma patients (senders); orthopaedic traumatologists who receive transfers (traumatologist receivers); and other trauma transfer receivers that are not traumatologists (non-traumatologist receivers). The perceived complexity and appropriateness for transfer of eight virtual case scenarios were determined, along with the specific reasons mitigating transfer.51 Senders, 90 traumatologist receivers, and 98 non-traumatologist receivers completed 239 surveys. There was agreement between groups for case complexity and appropriateness for transfer in five of eight case scenarios (p<0.05). Fracture complexity was cited as the primary reason for transfer by 28% of senders. However, just as common was a lack of resources at the sending hospital; OR equipment (18%), critical care services (18%), and inability to handle the immediacy of the case (7%) were also cited. Likelihood of uninsured status was the least common reason for transfer (1%).In most cases, both senders and receivers of orthopaedic trauma have similar viewpoints regarding fracture complexity and appropriateness of transfer. Sending surgeons cite case complexity and a lack of hospital resources as the primary reasons for patient transfer. Mandating increased call for orthopaedic surgeons at non-trauma centres without a concomitant increase in hospital resources is unlikely to substantially reduce unnecessary patient transfers to higher level facilities.

Abstract

The purpose of this study was to determine if surgeons could reliably predict if patients with tibia fractures treated with intramedullary nails will proceed to nonunion based on their clinical scenario and radiographs at 3 months.Blinded randomized questionnaire based on a retrospective cohort.University level 1 trauma center.Fifty-six patients who underwent intramedullary fixation for tibia fractures with incomplete healing at 3 months.A questionnaire was applied to 56 consecutive patients treated between 2005 and 2009 with intramedullary fixation for tibia fractures who had incomplete healing at 3 months. Each case was developed into a vignette that included the 3-month radiographs and detailed clinical histories. The questionnaire was distributed to 3 fellowship-trained trauma surgeons who were asked to predict if the fracture would go onto nonunion.Diagnostic accuracy of predicting nonunion in patients with incomplete healing of their tibia fracture at 3 months.The combined overall diagnostic accuracy of all 3 surgeons was 74%. Sensitivity and specificity was 62% and 77%, respectively. Radiographic features and injury mechanism were the most commonly cited clinical information used to predict fracture healing. The average positive predictive value was 73%. In 9 patients with diabetes, the diagnostic accuracy was 88%.Clinical judgment at 3 months allows for correct prediction of eventual nonunion development in a majority of patients. We suggest that analysis of the entire clinical picture be used to predict fracture healing at 3 months. A protocol of waiting for 6 months before reoperation in all patients treated with intramedullary nailing for tibia fractures may subject patients to prolonged disability and discomfort.Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Abstract

To evaluate the impact of computerized tomography (CT) scan on both fracture classification and surgical planning of patellar fractures.Prospective study.Academic level I trauma center.Four fellowship-trained orthopaedic trauma surgeons analyzed radiographs of 41 patellar fractures. Each fracture was classified (OTA/AO classification), and a treatment plan was developed using plain radiographs alone. The process was repeated (4-6 weeks later) with addition of CT scan. After 12 months, the 2-step analysis was repeated and interobserver reliability and intraobserver reproducibility were assessed.Suboptimal intra- and interobserver reliability was found for the surgical plan and classification using the OTA/AO system, despite the addition of a CT scan. After addition of CT, reviewers modified the classification in 66% of cases and treatment plan in 49%. CT frequently demonstrated a distinctive and severely comminuted distal pole fracture; this fracture pattern was present in 88% of cases and was unappreciated on plain radiographs in 44% of those cases. This pattern is unaccounted for by the present OTA/AO classification.CT facilitates improved delineation of patellar fracture patterns. Understanding the distal pole fracture pattern is fundamental in choosing a fixation construct. A fracture-specific classification system, based on CT scans, should be developed.

Abstract

The incidence of osteoporotic fractures has been steadily rising along with the aging of the population. Surgical management of these fractures can be a challenge to orthopedic surgeons. Diminished bone mass and frequent comminution make fixation difficult. Advancements in implant design and fixation techniques have served to address these challenges and when properly applied, can improve overall outcome. The purpose of this review is to describe fixation challenges of common osteoporotic fractures and provide options for successful treatment.

Abstract

Proximal humeral fractures are extremely common injuries, and are one of the true osteoporotic fractures. Most fractures can be effectively treated nonoperatively, as the rich vascularity and broad cancellous surfaces impart a high propensity for healing. Additionally, many fracture patterns result in adequate bone contact and minimal displacement with acceptable alignment. Open reduction and internal fixation of displaced fractures can improve outcomes, depending on the pre-injury functional status of the patient. If operative treatment is selected, unique treatment challenges must be overcome, including obtaining and maintaining reduction of small bone fragments with strong muscle forces, often in osteoporotic bone. Many options are feasible, including plates, nails, sutures, and other novel devices. Locking plates are the most common device used, but technical detail is critical to minimize the risk of implant failure, loss of reduction, and reoperation.

Abstract

Femoral head fractures may present in various patterns with or without associated fractures around the hip. As a result, the treating orthopaedic surgeon must understand not only the fracture pattern, but also patient-related fractures and the relevant operative exposures and reconstructive options to achieve the best functional outcome while minimizing complications. Treatment options range from non-operative treatment to fracture fragment excision or fracture fixation using various surgical exposures and implants. This article reviews the current literature on the treatment options for femoral head fractures and presents modern operative techniques that have improved exposure of the fracture while minimizing associated risks such as avascular necrosis, heterotopic ossification, and neurovascular compromise. A sound understanding of the anatomy and these newer techniques can enable the surgeon to provide improved expectations and clinical outcomes.

Abstract

Spinal hardware has been adapted for fixation in the setting of anterior pelvic injury. This anterior subcutaneous pelvic fixator consists of pedicle screws placed in the supraacetabular region connected by a contoured connecting rod placed subcutaneously and above the abdominal muscle fascia.We examined the placement of the components for anterior subcutaneous pelvic fixator relative to key vascular, urologic, bony, and surface structures.We measured the CT scans of 13 patients after placement of the pelvic fixator to determine the shortest distances between the fixator components and important anatomic structures: the femoral vascular bundle, the urinary bladder, the cranial margin of the hip, the screw insertion point on the bony pelvis, the relationship between the pedicle screw and the corridor of bone in which it resided, and the position relative to the skin.The average distance from the vascular bundle to the pedicle screw was 4.1 cm and 2.2 cm to the connecting rod. The average distance from the connecting rod to the anterior edge of the bladder was 2.6 cm. The average distance from the screw insertion point to the hip was 2.4 cm; none penetrated the hip. The average screw was in bone for 5.9 cm. The pedicle screws were on average 2.1 cm under the skin. The average distance from the anterior skin to the connecting rod was 2.7 cm.Components of this anterior pelvic fixator are close to important anatomic structures. Careful adherence to the surgical technique should minimize potential risk.Level IV, retrospective study. See Guidelines for Authors for a complete description of levels of evidence.

Abstract

Acute traumatic pelvic instability mandates reduction and mechanical stabilization to maximize the chance of a good functional outcome. Posterior pelvic fixation is frequently inadequate to stabilize the pelvic ring in isolation. Fixation augmentation with anterior pelvic ring implants can take several forms, including plates, medullary screws, or external fixation. Based on a multitude of patient and injury factors, external fixation may be the definitive anterior pelvic implant of choice. However, many drawbacks exist with this treatment, most notably the high infection rates of the transcutaneous pins, impaired patient mobilization, and suboptimal mechanical properties. We present a technique of a subcutaneous anterior pelvic fixator as an alternative method of anterior pelvic ring reduction and stabilization that avoids many of the drawbacks of traditional anterior pelvic external fixation.

Abstract

Biomechanical testing of fracture fixation implants is crucial in preclinical evaluation and in comparing new devices with standard devices. Many variables must be considered when planning and implementing a biomechanical in vitro experiment. The type of test selected (eg, load-to-failure, stiffness, cyclic fatigue) depends on the research question being asked. For example, cyclic fatigue testing attempts to replicate clinical situations; thus, the load magnitudes and directions and the number of cycles should be decided accordingly. Most important, each bone and region of bone experiences specific in vivo forces based on muscular and other forces. Debate persists regarding whether cadaver or synthetic bone is optimal. The use of either material in biomechanical testing should be carefully considered and justified in the context of the study hypothesis. Appropriate study design is the main factor that affects the clinical applicability of the findings and the accuracy of the conclusions.

Abstract

Despite design features intended to aid the surgeon in restoring proper alignment, malunion and implant-related problems are relatively common after a distal femur fracture treated with plate fixation. This article presents case examples of these problems followed by a discussion of the relevant distal femoral anatomy, design features of modern locked distal femur plating systems, and technical points necessary to avoid malunion and implant-related problems when using these devices.

Abstract

Unstable and displaced proximal humerus fractures remain a treatment challenge. The use of locked plates has improved construct stability, but complication rates remain high. Biomechanical studies have emphasized the importance of anchoring screws in the subchondral bone of the humeral head to improve implant stability. However, the spherical shape of the proximal humerus and the limited tactile sensation of its soft cancellous bone make determining accurate screw length difficult, and reported rates of intraoperative screw penetration are high. Iatrogenic screw penetration, even if recognized and corrected before leaving the operating room, may lead to late failure. We present a simple technique of quickly and safely determining screw length using a blunt-tipped Kirschner wire and instruments found in basic orthopaedic sets.

Abstract

To evaluate the prevalence and magnitude of sagittal plane deformity in bicondylar tibial plateau fractures.Retrospective radiographic review.Two Level I trauma centers.Sagittal inclination of the medial and lateral plateau measured in relation to the longitudinal axis of the tibia using computed tomographic reconstruction images.Seventy-four patients (mean age, 49 years; range, 16-82 years; 64% male) with acute bicondylar tibial plateau fractures (Orthopaedic Trauma Association 41C, Schatzker VI) treated from October 2006 to July 2009.The average sagittal plane angulation of the lateral plateau was 9.8 posteriorly (range, 17 anteriorly to 37 posteriorly). The medial plateau was angulated 4.1 posteriorly on average (range, 16 anteriorly to 31 posteriorly). Forty-two lateral plateaus were angulated more than 5 from the "normal" anatomic slope (defined as 5 of posterior tibial slope). Of these, 76% were angulated posteriorly. Forty-three (58%) of the medial plateaus were angulated greater than 5 from normal, of which only 47% were inclined posteriorly (P = 0.019 compared with lateral plateaus). In 68% of patients, the difference between medial and lateral plateaus was greater than 5; the average intercondylar slope difference was 9 (range, 0-31; P < 0.001). Spanning external fixation did not affect the slope of either the medial or lateral tibial plateau. Intraobserver and interobserver correlations were high for both the medial and lateral plateaus (r > 0.81, P < 0.01).Considerable sagittal plane deformity exists in the majority of bicondylar tibial plateau fractures. The lateral plateau has a higher propensity for sagittal angulation and tends to have increased posterior slope. Most patients have a substantial difference between the lateral and medial plateau slopes. The identification of this deformity allows for accurate preoperative planning and specific reduction maneuvers to restore anatomic alignment.

Abstract

Typical posterior pelvic fixation constructs use one or more large screws inserted from the lateral iliac cortex into the safe upper sacral ala or body. As a result of the deforming forces acting perpendicular to the implant axis, routine iliosacral screw fixation may not provide adequate stabilization, especially in certain unstable injuries. Longer iliosacral screws that traverse the entire upper sacrum and exit the contralateral iliac cortex may improve holding power and also stabilize concomitant contralateral posterior pelvic injuries. These transiliac-transsacral screws are reliably safe to insert using routine intraoperative fluoroscopy, and they provide durable fixation. These screws require careful preoperative planning and more precise technical attention during insertion because they pass through both sacral alar zones. Transiliac-transsacral screws may be particularly useful in the presence of osteoporosis, significant posterior pelvic instability including spinopelvic dissociation, patient obesity, anticipated noncompliant behavior, bilateral posterior pelvic injuries, and nonunion procedures.

Abstract

The mechanisms underlying the interaction between the local mechanical environment and fracture healing are not known. We developed a mouse femoral fracture model with implants of different stiffness, and hypothesized that differential fracture healing would result.Femoral shaft fractures were created in 70 mice, and were treated with an intramedullary nail made of either tungsten (Young's modulus=410GPa) or aluminium (Young's modulus=70GPa). Mice were then sacrificed at 2 or 5weeks. Fracture calluses were analyzed using standard microCT, histological, and biomechanical methods.At 2weeks, callus volume was significantly greater in the aluminium group than in the tungsten group (61.2 vs. 40.5mm(3), p=0.016), yet bone volume within the calluses was no different between the groups (13.2 vs. 12.3mm(3)). Calluses from the tungsten group were stiffer on mechanical testing (18.7 vs. 9.7N/mm, p=0.01). The percent cartilage in the callus was 31.6% in the aluminium group and 22.9% in the tungsten group (p=0.40). At 5weeks, there were no differences between any of the healed femora.In this study, fracture implants of different stiffness led to different fracture healing in this mouse fracture model. Fractures treated with a stiffer implant had more advanced healing at 2weeks, but still healed by callus formation. Although this concept has been well documented previously, this particular model could be a valuable research tool to study the healing consequences of altered fixation stiffness, which may provide insight into the pathogenesis and ideal treatment of fractures and non-unions.

Abstract

To evaluate the variability of the ideal trochanteric starting point as a possible cause for malreduction of subtrochanteric fractures and to analyze the accuracy of contralateral templating to predict correct entry site.Standardized anteroposterior pelvis radiographs of 50 patients were evaluated by two independent reviewers. Patients with advanced osteoarthritis, severe hip deformity, and radiographs with asymmetric hip rotation were excluded. Ideal nail entry site was established using a template for a trochanteric nail with a 6 proximal bend. The distance from the greater trochanteric tip to the ideal nail entry site was measured. Additionally, offset of the greater trochanter tip from the femoral longitudinal axis was measured. Interobserver reliability and accuracy of contralateral templating were evaluated.The ideal entry point ranged from 16 mm medial to 8 mm lateral to the trochanteric tip (mean, 3 mm medial; standard deviation, 5 mm). In 70% of patients, the ideal entry point was medial to and in 23% lateral to the tip of the greater trochanter. Ideal entry points were located within 2 mm of the trochanteric tip in 29% and within 4 mm in 44% of patients. The location of the ideal entry point relative to the trochanteric tip had a weak correlation with patient height and neck shaft angle (r: -0.23 and r: -0.35, respectively). Interobserver reliability and agreement between left and right side measurements were strong (intraclass correlation coefficient: >0.94 and >0.88, P < 0.001, respectively). The mean measurement differences between sides was 0 mm (95% confidence interval: -1 to 1). Greater trochanter offset averaged 15 mm (range, 5-26 mm; standard deviation: 5) on the right and 15 mm (range, 5-25 mm; standard deviation: 5.1) on the left (P = 0.95).A high degree of variability exists for the ideal trochanteric entry site. The trochanteric tip represents the ideal starting point in only the minority of cases. Preoperative contralateral templating provides an accurate means for establishing a patient-specific entry point to minimize fracture malreduction.

Abstract

Hip fractures in the elderly are associated with high 1-year mortality rates, but whether patients with other lower extremity fractures are exposed to a similar mortality risk is not clear.We evaluated the mortality of elderly patients after distal femur fractures; determined predictors for mortality; analyzed the effect of surgical delay; and compared survivorship of elderly patients with distal femur fractures with subjects in a matched hip fracture group.We included 92 consecutive patients older than 60 years with low-energy supracondylar femur fractures treated between 1999 and 2009. Patient, fracture, and treatment characteristics were extracted from operative records, charts, and radiographs. Data regarding mortality were obtained from the Social Security Death Index.Age-adjusted Charlson Comorbidity Index and a previous TKA were independent predictors for decreased survival. Congestive heart failure, dementia, renal disease, and history of malignant tumor led to shorter survival times. Patients who underwent surgery more than 4 days versus 48 hours after admission had greater 6-month and 1-year mortality risks. No differences in mortality were found comparing patients with native distal femur fractures with patients in a hip fracture control group.Periprosthetic fractures and fractures in patients with dementia, heart failure, advanced renal disease, and metastasis lead to reduced survival. The age-adjusted Charlson Comorbidity Index may serve as a useful tool to predict survival after distal femur fractures. Surgical delay greater than 4 days increases the 6-month and 1-year mortality risks. Mortality after native fractures of the distal femur in the geriatric population is high and similar to mortality after hip fractures.Level II, prognostic study. See the guidelines online for a complete description of evidence.

Abstract

Operative indications for surgical treatment of posterior malleolar fractures associated with fractures of the distal fibula and tibia are not currently well defined. The purpose of the present study was to determine the current practice among orthopaedic surgeons regarding the management of posterior malleolus fractures.Web-based questionnaires were emailed to members of the Orthopaedic Trauma Association (OTA) and American Orthopaedic Foot and Ankle Society (AOFAS). Requested information included demographics and treatment preferences for five clinical scenarios with different fracture characteristics. Four hundred one respondents completed the survey (20% response rate). Ninety eight (24%) subjects had received specialty training in orthopaedic trauma, 199 (50%) in foot and ankle (F&A) surgery and six (2%) in both orthopaedic trauma and F&A surgery. Ninety five (24%) had either no or other specialty training.The most frequently reported indication for fixation was not based on a fragment size threshold, but rather was ``depends on stability and other factors'' (56%). Trauma surgeons, those with less than 10 years experience, and those who treated more than five ankles fractures per month were significantly more likely to use factors other than size for indications (p = 0.026, <0.01, and <0.01, respectively). Despite this general response, fragment size still affected treatment decisions. A fragment comprising 50% of the articular surface was indicated for fixation by 97% of respondents, while a size of 10% would be treated by only 9% of respondents. For a posterior fragment with 20% articular involvement and a small free osteochondral fragment, fixation was deemed necessary by 44% of respondents. There were no differences in fellowship training, years of experience in practice, or ankle fracture volume per month in these three situations. A larger proportion of trauma trained surgeons considered fixation necessary compared to F&A trained surgeons in this case (p = 0.028). When posterior malleolus fixation was indicated for a large fragment, direct open reduction using the flexor hallucis longus -peroneal tendon interval was the most commonly selected approach in all cases. Trauma-trained surgeons were significantly more likely to choose antiglide plate fixation compared to screw-only fixation (p < 0.05).In this survey study of trauma and F&A surgeons, significant variation existed regarding most aspects of posterior malleolar ankle fracture treatment. Most notably, factors other than fragment size most impacted surgical indications. Newer techniques such as direct exposure and plating of the posterior malleolus are chosen more frequently than traditional techniques of indirect reduction and percutaneous screw fixation.

Abstract

The surgical management of pilon fractures has evolved over the last several years with treatment shifting from acute definitive fixation to delayed fixation. One of the driving forces behind this change was the high incidence of soft tissue complications in those patients with high-energy pilon fractures (Orthopaedic Trauma Association 43B and 43C) managed with acute stabilization. Meticulous soft tissue handling along with delayed definitive fixation based on the soft tissue envelope has decreased the short-term complications associated with treatment of these injuries. Anterolateral exposure to the distal tibial articular surface allows for adequate visualization of most fracture patterns, novel reduction strategies, and successful implant placements. This exposure is useful in certain Type C pilon fractures, anterior and anterolateral Type B pilon fractures, and some extra-articular distal tibial fractures. The anterolateral exposure is not suitable in fractures with medial comminution, medial crush, impaction at the medial shoulder of the joint, segmental medial malleolar injuries, or varus deformity at the time of injury. The exposure has the advantage of excellent visualization of the articular surface up to the medial shoulder of the plafond while avoiding dissection of the anteromedial tibial surface.

Abstract

Given the ongoing epidemic of obesity, femoral fracture management in the population affected by this condition is likely to become more frequent. Fracture treatment in obese patients poses a special challenge given greater difficulty in establishing an accurate diagnosis and confirming associated injuries. Adequate intraoperative positioning and obtaining accurate reduction and stable fixation may require special considerations. Obese patients have a high predisposition for complications such as compartment syndrome, nerve injuries, and pressure ulcers, and are at increased risk for medical complications given the high prevalence of comorbidities. A thorough understanding of the risks associated with obesity and the diagnostic and therapeutic challenges involved with femoral shaft fractures in this setting is paramount to achieve adequate results.

Abstract

Interprosthetic femoral fractures, ones occurring between ipsilateral total hip and total knee arthroplasties, are an increasingly common and challenging problem for orthopaedic surgeons. The purpose of this study was to report specific fracture locations and treatment outcomes associated with a protocol of femoral plate fixation that spanned the interprosthetic zone applied with modern soft tissue preserving reduction techniques without adjuvant bone grafts.Retrospective cohort study.One Level I and one Level II trauma center.A consecutive cohort of 25 patients with 26 interprosthetic femur fractures surgically treated by one of four orthopaedic traumatologists were retrospectively reviewed. There were nine fractures of the femoral shaft (Orthopaedic Trauma Association [OTA] 32) about hip arthroplasty prostheses and 17 supracondylar fractures (OTA 33) about total knee prostheses. Five patients with six fractures were excluded as a result of lack of follow up (n = 4) or deviation from the treatment protocol (n = 2). The remaining 20 fractures were all low-energy closed injuries in elderly patients (average age 80 years; range, 56-98 years; 14 females and six males).A common surgical treatment protocol included plate fixation that spanned the entire interprosthetic zone (overlapping the stem proximally and knee component distally) and the use of biologic tissue-preserving plating techniques without use of supplemental bone grafts of any kind.Fracture healing, time to full weightbearing, malunion, nonunion, and the presence of any hardware failure.Supracondylar interprosthetic fracture patterns (OTA 33A) were two times more common than proximal diaphyseal fractures (OTA 32) (Vancouver B), 65% versus 35%. All 20 fractures healed after the index procedure. The average time to weightbearing as tolerated was 13 weeks (range, 6-22 weeks). There were three malunions (one 10 valgus, one 9 extension, and one 10 flexion), two cases of painful implants (one required removal), and one loose long-stem revision hip prosthesis (required total femur replacement). All other implants remained well-fixed. All complications occurred in patients with supracondylar fracture patterns. There were no additional associated peri-implant fractures.Interprosthetic femoral fractures tend to occur more frequently in the supracondylar region about total knee arthroplasty components than in the diaphysis about hip stems. Modern biologic plating techniques that span the entire interprosthetic zone to eliminate additional stress risers show reliable union rates without the use of adjuvant bone graft while maintaining limb alignment and implant survivorship.

Abstract

The most common implants for treating unstable femoral neck fractures are sliding constructs, which allow postoperative collapse. Successful healing, typically, is a malunion with a shortened femoral neck. Functional sequelae resulting from altered femoral neck biomechanics have been increasingly reported. Re-operation rate due to nonunion, avascular necrosis, hardware cut-out and prominence is high with this treatment modality. We evaluated the outcomes of patients with femoral neck fractures treated with stable calcar pivot reduction, intraoperative compression across the fracture, and stabilization with length-stable implants.Fifty-four patients with femoral neck fractures underwent open reduction and internal fixation. Average follow up duration was 23.6 months (range: 15-36 months). There were 23 Garden I, 2 Garden II, 14 Garden III and 15 Garden IV fractures. Reduction was achieved through a modified Smith-Petersen approach. Fractures were compressed initially, and subsequently stabilized with a length-stable device. Post-operative radiographs were assessed for change in fracture alignment. Variation in the femoral neck offset and abductor lever arm measurements was performed using the contralateral hip as control. Functional outcome was assessed using SF-36, Harris Hip Score (HHS) and a gait analysis device. The average patient age was 78 years. Fifty-one (94%) healed without complications. Surgical fixation failed in two patients and one patient developed avascular necrosis. The average femoral neck shortening was 1.7 mm.The average difference in femoral neck offset and the abductor lever arm measurement at the latest follow up was 3.5 and 1.5 mm respectively. The average score on physical, mental components of SF-36 and HHS was 42 and 47 and 87 respectively. By 6 months, patients on average recovered 94% of the single limb stance time, 98% of cadence, 90% of cycle duration, 96% in stride length compared to the uninjured side.Reduction with a stable calcar pivot, intraoperative compression and length-stable fixation can achieve high union rates with minimal femoral neck shortening and improved functional outcomes.IV, retrospective with historical controls.

Abstract

To quantify the obliquity and dimensions of the upper and second sacral segment iliosacral screw safe zones and to determine the differences between normal and dysmorphic sacral morphology.Retrospective cohort.University Level I trauma center.Fifty patients with pelvic computed tomography scans.All sacra were characterized as normal or dysmorphic based on plain pelvic radiographs and previously described criteria. Multiple computed tomography scan reconstructions were viewed and manipulated simultaneously with 6 degrees of freedom to allow for custom visualization in any plane.In each patient, a unique reconstruction plane was created perpendicular to the safe zone axis. The narrowest safe zone cross-sectional area was measured. Next, on simulated pelvic outlet and inlet views, safe zone obliquity and width were measured. Finally, the space available for a transverse screw was assessed. Measurements were performed for both upper and second sacral segment. Values for normal and dysmorphic safe zones were compared.Sacral dysmorphism was identified in 22 patients. In these sacra, the upper sacral segment safe zone cross-section was 36% smaller than in normal sacra (P < 0.001). No transverse screws could be placed, but accommodating for the caudal to cranial obliquity (30 versus 21 in normals, P < 0.001) and posterior to anterior obliquity (15% versus 4% in normals, P < 0.001) of the safe zone, an iliosacral screw at least 75 mm in length could be placed safely in 91% of patients. A transverse screw could be placed in 75% of normal sacra. In the second segment safe zone, the cross-sectional area was more than twice as large in dysmorphic sacra compared to normals (220 mm versus 109 mm, P < 0.001). The obliquity was not different on either the inlet or outlet views between groups. A transverse screw could be placed at this level in 95% of those with dysmorphic sacra and in only 50% of normal sacra.Sacral dysmorphism occurred in 44% of patients in this consecutive series. Many anatomic differences were consistently found between the two morphologies with clinical relevance to iliosacral screw placement. Specifically, the dysmorphic upper sacral segment safe zone is significantly smaller and more obliquely oriented but is still large enough to accommodate an iliosacral screw in nearly all patients. The second sacral segment safe zone is approximately transversely oriented in both sacral types but is more than twice as large in dysmorphic sacra. This segment may be a primary fixation opportunity in patients with sacral dysmorphism.

Abstract

Acute traumatic pelvic ring injuries are associated with life-threatening hemorrhage related to pelvic instability. Rapid and effective methods to mechanically stabilize the pelvic injury are often a prerequisite for patient survival. Most of these methods have significant disadvantages because of either difficult application or limited efficacy. Pelvic antishock clamp placement is difficult and dangerous, and circumferential pelvic antishock sheeting is not universally effective in reducing and stabilizing the pelvic ring. We describe a technique of acute posterior pelvic ring reduction and stabilization using a percutaneously inserted iliosacral screw as a resuscitation adjunct.

Abstract

Musculoskeletal plain radiographic imaging protocols are typically predicated on orthogonal views of the bone or joint being evaluated. Pelvic injury has been evaluated with 45 degrees inlet and 45 degrees outlet radiographs. While these views are perpendicular to each other, they may not be in the best plane to evaluate pelvic injury because of variable lumbopelvic anatomy. We hypothesized that inlet and outlet radiographic views optimized to examine the clinically relevant osseous landmarks vary substantially from routine 45 degrees inlet and outlet views.Sixty-eight consecutive patients without pelvic ring disruption who had undergone routine axial pelvic computed tomography scans were retrospectively identified. The optimal inlet and outlet angles required to profile the clinically relevant pelvic anatomy were quantified for each patient with use of sagittal computed tomography reconstructions.The optimal inlet angle to profile the anterior body of S1 required an average caudal tilt of 21 degrees . The average outlet angle (cephalad tilt) perpendicular to the body of S1 was 63 degrees and perpendicular to S2 was 57 degrees . The optimal angles were the same for male and female patients and for patients with normal and dysmorphic pelves and were independent of patient age.Screening inlet and screening outlet radiographs made at 25 degrees and 60 degrees , respectively, are recommended to provide accurate profiles of the clinically relevant posterior osseous pelvic anatomy.

Abstract

The purpose of this study was to determine the ability of intramedullary fibular fixation to maintain reduction until healing and to determine the overall complication rate in high-energy pilon fractures associated with fibular fractures.Retrospective study.Level I university trauma center.From 2000 to 2007, 972 pilon fractures were treated at our institution, 38 of which were treated with an intramedullary device for the associated fibular fracture. Two patients had acute amputations and two died; 1-year follow-up was obtained in 27 of the remaining patients. Average length of follow-up was 21 months.A retrospective chart and radiograph review was conducted of all patients for data extraction.Fibular fixation type and length, fibular healing, and complications.Average patient age was 36 years (range, 18-59 years). Four of the fibular fractures were segmental. All fractures had at least 50% of the cortex intact to prevent shortening. The average height of the fibular fractures from the distal tip was 6.9 cm (range, 1.3-22.2 cm). In 20 patients, a 3.5-mm fully threaded cortical screw was used for stabilization, and in the remaining seven, a 2.5-mm wire was used. The intramedullary implant extended 8.5 cm above the most proximal fracture line on average (range, 1.6-29.8 cm). Fibular alignment was within 3 degrees of anatomic in all cases after initial fixation. At final follow-up, fibular alignment had not changed more than 1 degrees in any case. No complications related to the fibular incision occurred, and all fibula fractures healed within 3 months.In axially and rotationally stable fibular fracture patterns associated with pilon fractures, intramedullary fibular stabilization was effective in maintaining fibular alignment. This technique led to reliable fracture healing in appropriately selected fractures and may be particularly advantageous in patients with compromised lateral and posterolateral soft tissues.

Abstract

A healed, yet shortened, femoral neck has historically been deemed a success in fracture treatment. This, however, comes at the price of diminished physical function and quality of life. We analyzed the outcomes of our treatment algorithm, which attempts to minimize postoperative shortening of femoral neck fractures and determined which preoperative factors were associated with femoral neck shortening and failure of surgical fixation.This is level IV retrospective study.Fifty-four patients underwent open reduction and internal fixation for acute femoral neck fracture with nonsliding constructs. The collapse of the femoral neck in the horizontal (X), vertical (Y), and along the resultant along the (Z) vector (X+Y=Z) was measured on anteroposterior radiographs corrected for leg rotation. The migration of the superior-most screw tip in all axes was measured. Age, gender, Garden grade, and Pauwel's angle were analyzed for their association with shortening or failure of surgical fixation.The average age of the patients was 78.1 years. There were 23 Garden I, 2 Garden II, 14 Garden III, and 15 Garden IV fractures. Fifty-one (94%) healed successfully without complications. The minimum follow-up was 9 months (average, 17.6 months; range, 9-30 months). Surgical fixation failed in two patients, and one patient developed avascular necrosis. The average displacement of the femoral head and the screw tip was 1.23, 0.86, 1.98 mm and 0.7 mm, 0.9 mm, and 1.7 mm in the X, Y, and Z (resultant) vectors, respectively.With careful consideration to reduction, we fixed femoral neck fractures with nonsliding constructs, resulting in a high union rate with very minimal shortening of the femoral neck.

Abstract

Locked plating leads to improved fixation in osteoporotic bone. In addition, experimental data suggest that overall construct stiffness is increased. Ideal stiffness may be significantly less than that achieved with these locked constructs, and overly stiff constructs may lead to impaired fracture healing and stress concentration at the ends of the plate. In osteoporotic bone, this stiffness mismatch can be even more pronounced. We hypothesized that substituting slots for holes in the near cortex under a locked plate would lead to predictably lower stiffness without diminishing implant stability.Osteoporotic bone substitute segments were used. Locking screws and plates were applied to each specimen using either standard holes or near cortical slots. The slots were designed to allow axial displacement of the screw in the near cortex only, while continuing to provide some torsional stability. Mechanical testing was performed using a progressive dynamic displacement load protocol to determine failure and stiffness. Next, cyclic axial loading was performed with a physiologic load for 10,000 cycles to determine change in stiffness with cycling. Outcomes were compared between groups using Mann-Whitney U tests.In the dynamic displacement tests, the slotted specimens reached both maximum load and failure load at a significantly greater displacement than the non-slot group (p=0.008), indicating later failure. The magnitude of the maximum load achieved was no different between groups. In the cyclic loading tests, the axial stiffness in the slotted group was significantly lower (1199 N/mm) than the non-slotted group (3538 N/mm; p<0.05 at all cycles). Stiffness did not change significantly in either group over the course of cycling.The ability to predictably adjust the axial stiffness of locked plating constructs is critical, particularly in osteoporotic bone. The use of near cortical slots decreases axial stiffness of locking plates, while maintaining fixation stability. This may allow the surgeon to more closely tailor the construct stiffness to the clinical situation to minimize stiffness mismatches and complications.

Abstract

It is unclear whether there is a limit to the amount of distal bone required to support fixation of supracondylar periprosthetic femoral fractures. This retrospective multicentre study evaluated lateral locked plating of periprosthetic supracondylar femoral fractures and compared the results according to extension of the fracture distal with the proximal border of the femoral prosthetic component. Between 1999 and 2008, 89 patients underwent lateral locked plating of a supracondylar periprosthetic femoral fracture, of whom 61 patients with a mean age of 72 years (42 to 96) comprising 53 women, were available after a minimum follow-up of six months or until fracture healing. Patients were grouped into those with fractures located proximally (28) and those with fractures that extended distal to the proximal border of the femoral component (33). Delayed healing and nonunion occurred respectively in five (18%) and three (11%) of more proximal fractures, and in two (6%) and five (15%) of the fractures with distal extension (p = 0.23 for delayed healing; p = 0.72 for nonunion, Fisher's exact test). Four construct failures (14%) occurred in more proximal fractures, and three (9%) in fractures with distal extension (p = 0.51). Of the two deep infections that occurred in each group, one resolved after surgical debridement and antibiotics, and one progressed to a nonunion. Extreme distal periprosthetic supracondylar fractures of the femur are not a contra-indication to lateral locked plating. These fractures can be managed with internal fixation, with predictable results, similar to those seen in more proximal fractures.

Abstract

The management of unstable pelvic ring injuries is complex. Displacement is a clear indication for surgical intervention. However, reduction of acute pain after stabilization may have substantial clinical benefits and affect management decisions. The purpose of this study was to determine the impact of operative fixation of unstable pelvic ring injuries in diminishing acute pain.During a 33-month period, 70 patients with isolated pelvic ring injuries were managed at a Level-1 trauma center and retrospectively reviewed. On the basis of clinical and radiographic instability, 38 patients were managed surgically and formed the study group. Pain was assessed using visual analog scales and narcotic consumption during the index hospitalization.In the operative group, visual analog scale scores decreased 48% after fixation from 4.71 +/- 1.8 preoperatively to 2.85 +/- 0.8 postoperatively (p < 0.001). Concomitantly, narcotic requirements decreased 25% from 2.26 mg morphine per hour preoperatively to 1.71 mg morphine per hour postoperatively (p = 0.024). The mean total length of hospital stay was 5.6 days (SD, 1.2 days), and the postoperative length of hospital stay was 4.7 days (SD, 1.2 days).Operative reduction and fixation of unstable pelvic ring injuries significantly decreases acute pain. This has substantial physiologic benefits, particularly by improving mobilization, and should be an additional factor when determining surgical indication and timing.

Abstract

Osteoporosis remains underdiagnosed in orthopaedic trauma patients. Recently, protocols have emerged to identify and treat osteoporosis in this population. Our purpose was to compare the usefulness of quantitative ultrasound of calcaneus (QUS) with dual-energy x-ray absorptiometry (DXA) for identifying orthopaedic trauma patients at risk for osteoporotic fractures.A retrospective review of an osteoporosis screening protocol comparing QUS and DXA.Regional trauma center.Three hundred sixty consecutive hospitalized orthopaedic trauma patients treated by a single surgeon.QUS T-score and DXA bone mineral density T-scores (hip or radius) were obtained relative to U.S. normative data.QUS and DXA data were statistically compared to analyze their relationship. Potential thresholds for osteoporosis risk were subsequently defined.Testing was successfully performed with heel QUS in 350 patients and with DXA in 129 patients. One hundred twenty-six patients underwent testing with both modalities. According to World Health Organization criteria, 17% of patients tested with DXA had osteoporosis. A good predictive relationship between hip bone mineral density, as estimated by calcaneal QUS, and direct DXA measurement was seen (Pearson's r correlation coefficient of 0.53; area under the curve of 0.84 with 95% confidence interval=0.75-0.90; P=0.0001). QUS T-score cutoffs of greater than -0.9 resulted in 90% sensitivity (defining low osteoporosis risk) and a threshold of -1.6 or less resulted in a specificity of 80% (defining high osteoporosis risk).Substantial logistical difficulties are inherent in attempting to obtain DXA scans in orthopaedic trauma patients at our regional trauma center. For those patients who did undergo DXA, a strong predictive relationship was seen between hip bone mineral density and QUS parameters. QUS thresholds in defining low- and high-risk subjects for osteoporosis in this population using this device are proposed. QUS is a simple, reliable, and relatively inexpensive tool for evaluating osteoporosis risk in orthopaedic trauma patients.

Abstract

Rotational malalignment during femoral nailing is common. The difference in cortical width of the proximal and distal fracture fragments, the cortical step sign, is a commonly used yet poorly studied method of evaluating rotational alignment. This study aims to critically analyze the cortical step sign in cadaveric specimens using radiographic and direct measurements.One-centimeter segments from 20 cadaveric femora were harvested from the proximal, middle, and distal diaphyses. The medial and lateral cortical widths were measured in neutral and at 10 degrees , 20 degrees , and 30 degrees of internal rotation and external rotation directly from the gross specimens and indirectly using radiographs and cross-sectional imaging.Anatomic, radiographic, and cross-sectional imaging measurements all demonstrated that cortical width changes with femoral rotation. Rotation (both internal rotation and external rotation) of the proximal and middle segments led to a decrease in medial cortical width and lateral cortical width in 70% to 100% of samples (up to 2.2 mm, or 20% of cortical width) indicating that the cortices are thickest directly medially and laterally in neutral rotation. In the distal femur, however, internal rotation and external rotation led to an increase in medial cortical width and lateral cortical width in 80% to 95% of cases (up to 1.75 mm), except in the case of the medial cortical width in internal rotation, which decreased in 80% of the specimens (up to 1.3 mm).The cortical step sign, or incongruity of cortical widths on either side of a femur fracture, is indicative of rotational malreduction. Whether such malreduction is the result of internal rotation or external rotation, however, cannot be easily determined from this radiographic sign.

Abstract

Determining pelvic ring stability after a fracture is vital to treatment decisions. Commonly used information includes the displacement seen on initial radiographs. Static imaging studies may misrepresent the maximal amount of traumatic displacement at injury. We hypothesized that postinjury radiographs do not reveal maximal displacement of pelvic ring fractures. We also sought to determine whether different injury patterns and varying severity of displacement lead to different amounts of passive recoil.In 15 cadaveric pelvic specimens, unilateral anteroposterior compression (n = 7) or lateral compression (n = 8) injury patterns were experimentally created. A motion-tracking system was used to record rotational deformity of each hemipelvis before, during, and after fracture creation. The absolute and relative magnitudes of pelvic displacement and recoil after force relaxation were determined.In the simulated AO/OTA Type 61-B1.1 patterns (open book, rotationally unstable), maximal symphyseal diastasis recoiled by 48% +/- 18% (p < 0.05). In the AO/OTA Type 61-C1.2 patterns (open book, completely unstable), diastasis passively recoiled by 44% +/- 7% (p < 0.05). Lateral compression injuries (AO/OTA Type 61-B2.2) had maximal hemipelvis rotation of 41 degrees +/- 7 degrees and subsequently recoiled by 80% to 8 degrees +/- 6 degrees (p < 0.001).In this cadaveric model of simulated pelvic injury, a significant magnitude of passive recoil occurred after removal of the deforming force. The amount of recoil varied based on different injury patterns. However, the degree of recoil among specimens with similar injury patterns was generally consistent. In a clinical scenario, this suggests that only a portion of the maximal displacement that occurs at the time of injury is seen on initial plain radiographs. Injury severity should not be minimized based on pelvic displacement seen on initial static radiographs and computed tomographic scans.

Abstract

Failure of fracture fixation after plating often leads to challenging surgical revision situations. Careful analysis of all patient and fracture variables is helpful in both determining the causes of the fixation failure and maximizing the success of subsequent interventions. Biologic and mechanical factors must be considered. Biologic considerations include traumatic soft-tissue injury and atrophic fracture site. Common mechanical reasons for failure include malreduction, inadequate plate length or strength, and excessive or insufficient construct stiffness. Reliance on laterally based implants in the presence of medial comminution may be a cause of fixation failure and subsequent deformity, particularly with conventional nonlocking implants. Management of dead space with cement or beads has been effective in conjunction with staged approaches. An antibiotic cement rod in the diaphysis may provide fracture stabilization. Locking full-length constructs should be considered for osteoporotic fractures.

Abstract

Unstable pelvic ring injuries are associated with an increased mortality rate, most commonly from severe hemorrhage. Circumferential pelvic antishock sheeting has proven effective for rapidly stabilizing the pelvic ring and has become an integral part of resuscitation protocols. Acute antishock sheet placement frequently results in patient hemodynamic stabilization and an accurate pelvic reduction. In these situations, we describe a technique of maintaining the pelvic sheet position for continued use as a reduction aid and using working portals to insert definitive percutaneous pelvic implants.

Abstract

Anterior knee pain after intramedullary nailing of tibial shaft fractures is a common clinical problem, with various etiologies. We have used a lateral parapatellar approach with atraumatic elevation of the infrapatellar fat pad to expose the starting point. Our hypothesis was that this approach leads to a low incidence of knee pain.We conducted a retrospective study of 78 patients suffering from tibia fractures treated by a single surgeon. Fifty patients were available for the study. All fractures were fixed with a reamed intramedullary nail using the modified lateral approach. Complaints of knee pain and range of motion as well as keeling ability were examined in the clinic visit and recorded in the patients' charts. Lysholm knee scores were collected following the last follow-up visit. Average follow-up was 13 months (range 6-26 months).Nine patients (19%) had subjective anterior knee pain when directly questioned. Eighty-two percentage of patients had no difficulty kneeling and this was significantly correlated with lack of knee pain. Good or excellent knee scores were reported by 92% of patients. Average knee flexion was 130 degrees . There was a negative correlation between the presence of open fracture and outcome. No correlation was found between knee pain and nail insertion depth or coronal alignment.The modified lateral parapatellar approach with careful dissection of the fat pad may significantly reduce anterior knee pain after intramedullary nailing of the tibial shaft.

Abstract

To radiographically demonstrate the upper sacral nerve root tunnel (USNRT) in both cadaveric specimens and a clinical cohort and to quantify its clinical relevance.Level 1 trauma center and anatomy laboratory.Eleven cadaveric pelves and 23 consecutive patients who underwent fluoroscopically assisted iliosacral screw insertions.Cadaveric pelves were fluoroscopically imaged using standard pelvic inlet, outlet, and true lateral sacral views. The course of the USNRT pathway was identified. Then, these tunnels were filled completely with a semisolid radio-opaque agent. The specimens were reimaged after the contrast injection. Clinically, 23 consecutive patients with unstable posterior pelvic ring disruptions were treated using fluoroscopically assisted percutaneous iliosacral screws based on these predictable radiographic landmarks. A total of 44 iliosacral screws were inserted.For the cadaveric portion, the images with contrast were used to identify the USNRTs. For the clinical study, tunnel visualization was determined on all views intraoperatively. Screw placement was documented by postoperative pelvic plain radiographs and computed tomography scan.In the cadaveric specimens, the contrast agent consistently demonstrated the USNRTs on all 3 pelvic radiographic views. In the clinical series, the USNRTs were well visualized on the pelvic outlet image in all 23 patients (100%). Using the inlet image, the USNRTs were visualized in only 5 of 23 patients (21%). On the true lateral sacral views, the USNRTs were seen in 21 of 23 patients (91%). Using these USNRT radiographic landmarks, no iliosacral screw was extraosseous.The USNRTs have a consistent radiographic appearance that is best seen on the pelvic outlet and true lateral sacral views, but their course is best understood when seen on all 3 views. Awareness and understanding of the USNRT, its course, and its radiographic landmarks allow the surgeon to avoid tunnel intrusion by an iliosacral screw.

Abstract

Iliosacral screws are commonly used for fixation of pelvic ring injuries. Previous reports using different screw insertion techniques have reported high neurologic complication rates, leading to recommendations for intraoperative neurodiagnostic monitoring. The purpose of this study was to evaluate the neurologic complications after percutaneous iliosacral screw placement without neurodiagnostic monitoring.During a 21-month period, 326 patients with pelvic ring disruptions were treated at a level 1 trauma center. One hundred seventy-four patients underwent percutaneous stabilization of their pelvic ring injuries without neurodiagnostic monitoring. Patients who were not intubated preoperatively, were neurologically normal, and who underwent a closed reduction were included. Sixty-eight patients who had 106 screws placed met the inclusion criteria and formed the study group. A careful and detailed neurologic examination was performed preoperatively and postoperatively. Plain pelvic radiographs and computed tomography scans were evaluated postoperatively in all patients to assess screw position.No planned screw placement was abandoned because of inadequate fluoroscopic visualization. There were no neurologic injuries as a result of either the closed reduction or the screw placement. Computed tomography scans confirmed the screw position and demonstrated placement as intraosseous in 75 (70.8%) and juxtaforaminal in 31 (29.2%). No screws perforated a nerve root tunnel, spinal canal, or sacral cortex.Using a standardized technique, appropriate and reliable fluoroscopic landmarks are available in the vast majority of percutaneous iliosacral screw fixation procedures. Iliosacral screw placement without neurodiagnostic monitoring has a low rate of neurologic complications.

Abstract

External rotation of the disrupted hemipelvis is a common deformity after pelvic ring trauma, especially in anteroposterior compression injury patterns. This displacement is associated with significant pelvic hemorrhage. Emergent closed reduction techniques are necessary to diminish the potential pelvic volume, provide temporary stability, and allow tamponade with clot formation. Circumferential pelvic antishock sheeting is effective but may be cumbersome, especially in patients with truncal obesity. In such scenarios, circumferential pelvic area sheeting does not always achieve a complete reduction. We present a technique of internal rotation and taping of the lower extremities as an alternative or supplemental pelvic closed reduction method.

Abstract

Axial stiffness is a critical mechanical parameter in fracture plating. Standard locked plates allow minimal opportunities for stiffness alteration, and current methods are arbitrary and may lead to stiffness mismatch between the implant and bone. Milling the near cortex into a slot allows for an increase in translation of the screw shaft at the near cortex. The purpose of this proof of concept study was to determine the effects of slots on stiffness and their ability to maintain fixation of locking plates under cyclic loading.Using segments of fourth-generation synthetic diaphyseal bone, a simulated fracture with a gap was created and locked plates were applied with 4 bicortical locked screws in each fragment. On one fragment, the 4 near cortex holes were sequentially milled to 5 x 6-mm slots. Axial and torsional stiffnesses were determined for constructs with 0 through 4 slots. Specimens with 4 slots then underwent axial cyclic loading to determine the change in stiffness and loss of fixation. Extraction torque was measured for all screws to assess for screw loosening with cycling.In constructs with 4 slots, axial stiffness decreased by 73% (P < 0.05) relative to the 0-slot constructs. Torsional stiffness of the 3- and 4-slot specimens decreased by 20% (SD, 13%; P < 0.05) and 17% (SD, 13%; P < 0.05), respectively, compared with the 0-slot specimens. With cyclic loading, no failures occurred in any specimen. No change in stiffness had occurred by the end of cycling (106% of initial stiffness; SD, 4%; P = 0.96). No screw loosening occurred during cyclic loading.Purposeful stiffness modulation in fracture fixation is critical to facilitate uneventful fracture healing. Converting near cortical holes to slots allowed selective axial stiffness adjustment without sacrificing fixation stability under cyclic loading. With further refinement, this simple modification of standard implant application may allow the surgeon to decrease the modulus mismatch between plating constructs and bone to decrease the risk of fixation failure.

Abstract

In operative calcaneal fracture care malposition of screws and joint line incongruity frequently remain unrecognized using fluoroscopy intraoperatively, and are frequently only recognized on postoperative computed tomography scans. The purpose of this study was to analyze the feasibility and utility of a new C-arm-based three-dimensional imaging technology for calcaneal trauma care.The C-arm-based three- dimensional imaging device (ISO-C-3D) was used in 32 patients during a 2-year period. Patients were indicated for open reduction and internal fixation using standard techniques and fluoroscopy. After reduction and implant placement was determined to be correct, the ISO-C-3D procedure was performed. The time for setup and use, and the consequences were recorded. An assessment was obtained from the surgeon regarding the feasibility and the adequacy and quality of the data provided, using a Visual Analog Scale.The average total time required for ISO-C-3D use was 610 seconds. The information obtained from the scan led the surgeon to alter the reduction or screw placement during the procedure in 41% of the patients. Surgeons rating according to a Visual Analog Scale: feasibility 9.5, accuracy and quality 9.2, clinical benefit 8.2.Intraoperative three- dimensional visualization with the ISO-C-3D provides important information in the operative treatment of calcaneal fractures which cannot always be obtained from plain films or standard fluoroscopy alone. The use of the device adds minimal time to the overall procedure, and was found to be extremely useful in evaluating reduction and implant position intraoperatively in calcaneal fractures.

Abstract

Rotational malalignment after intramedullary nailing of femoral fractures is common, and symptoms occur when malrotation reaches 15 degrees . Intraoperative measurement of rotation remains difficult, and multiple techniques have been described to address this. Regardless of the method used, rotational toggling may occur between the interlocking screws and the screw holes. We hypothesized that a clinically significant amount of rotation may occur with standard statically locked intramedullary nails. Mid-shaft diaphyseal fractures were created in 24 cadaveric femurs. Specimens were divided into 4 groups, and were stabilized with a statically locked intramedullary nail, a dynamically locked intramedullary nail, a compression plate, and a locking plate. Six additional femurs were kept intact as a control group. Specimens were mounted in a custom holding jig, which stabilized the constructs proximally and allowed free rotation distally. A computer navigation system was applied, and the femoral anteversion was measured. 4 N-m of internal and external torque was applied, and the change in version was measured. The statically locked nails rotated 14.2 degrees , and the dynamically locked group rotated 15.7 degrees . Both intramedullary nail groups showed significantly greater rotation than the plated groups. The compression plate specimens rotated 6.5 degrees on average, and the locked plate group rotated 3.8 degrees . Intramedullary femoral nailing with static or dynamic interlocking allows 15 degrees of rotation of the femur around the nail under physiologic load. This may exacerbate intraoperative errors in determining and setting rotation. Angular stable plates or nails may minimize this problem.

Abstract

Sciatic nerve injury associated with acetabular fractures has been reported in most series. Typically, sciatic neuropraxia occurs from traumatic impaction or compression due to posterior hip fracture-dislocation. We report 2 patients with sciatic nerve entrapment within the posterior column components of their associated both-column acetabular fractures. Following neuroplasty through a Kocher-Langenbeck surgical approach, both patients' neurologic function improved. This unlikely cause of neurologic compromise should be considered in all patients with symptoms of sciatic nerve injury or irritation and particularly in the presence of a mechanical block during posterior column reduction through an ilioinguinal approach.

Abstract

Intraoperative visualization of articular surfaces is technically demanding, and standard two-dimensional fluoroscopic imaging frequently does not provide adequate detail of nonplanar joints. New imaging modalities allow for intraoperative 3D visualization, which are useful in articular fractures. Purpose of this study was to evaluate the utility of 3D imaging in articular fracture reconstruction.In a prospective cohort study, we evaluated 248 consecutive patients with intra-articular fractures. After fracture fixation using standard fluoroscopy, 3D imaging was performed intraoperatively using the Iso-C3D system for all patients. Surgeons filled out questionnaires regarding the utility and perceived accuracy of the 3D system. Postoperative CT scans were performed on approximately half of the patients. Main outcome measurements were based on the surgeons decision to immediately revise the articular reduction or implant position. The setup time for the system was recorded. For patients with postoperative CT scans, articular surface gaps of 2 mm or intra-articular hardware placement was again evaluated.In 19% of all cases, intraoperative image analysis resulted in immediate adjustment of the reduction or hardware exchange. These revisions were based on Iso-C3D views of the articular surface that were not visible using fluoroscopy. Of the 129 postoperative CT scans, five cases revealed a technical error of the joint reconstruction, and a secondary revision procedure was performed.In conclusion, the Iso-C3D was a valuable intraoperative tool, providing additional information about the articular surface compared with conventional fluoroscopy in a variety of anatomic regions.

Abstract

The traditional bipedicular kyphoplasty was proved to be safe and effective for the treatment of pain associated with osteoporotic vertebral compression fractures (VCFs). Nevertheless, unilateral kyphoplasty would be an attractive alternative to the traditional bipedicular kyphoplasty owing to theoretical speed, safety, and less expense; thus far, the biomechanical testing showed that experimental unilateral kyphoplasty had properties comparable with bipedicular kyphoplasty. To date, no clinical data are available regarding the efficacy and safety of unilateral balloon kyphoplasty. In this prospective observational study, the clinical and radiographic outcomes of the unipedicular (unilateral) balloon kyphoplasty in osteoporotic VCFs are evaluated.Three hundred and seventeen kyphoplasty procedures were performed in 142 patients with osteoporotic VCFs using the unilateral technique. This technique involves the unilateral cannulation of the center of the vertebral body and the placement of a single balloon tamp. To evaluate improvement in pain and physical function, preoperative and postoperative scores of visual analog scale (VAS), SF-36, and Oswestry Disability Index (ODI) were compared at 3 and 12 months postoperatively. Complications related to the procedure and cement extravasation rates were recorded. Height restoration and overall coronal and sagittal spinal alignment were assessed preoperatively and postoperatively.Significant improvement on the VAS, SF-36 scores, and ODI was noted at 3 months postoperatively; these results were preserved at the 12-month follow-up for the 30 patients who completed the SF-36 questionnaire (VAS/ODI scores were available only for 19 of the 30 patients also showing sustained improvement). No complication was recorded; 34 cases (10.73%) of cement extravasation were all asymptomatic. Mean middle height restoration was found 48.9%; when vertebral levels treated were stratified into 2 groups, with or without height restoration (90.1% and 9.9% of all levels, respectively), corrected mean middle height restoration was found 54%. No lateral wedging or changes in the coronal alignment was observed in the unipedicular group.Unipedicular (unilateral) extrapedicular kyphoplasty is both a safe and efficacious alternative to the traditional bipedicular kyphoplasty for the treatment of painful osteoporotic VCFs. As a technique, it is faster, less expensive, and involves less radiation exposure for the surgical suite personnel.

Abstract

The inferior gluteal artery is described in standard anatomy textbooks as contributing to the blood supply of the hip through an anastomosis with the medial femoral circumflex artery. The site(s) of the anastomosis has not been described previously. We undertook an injection study to define the anastomotic connections between these two arteries and to determine whether the inferior gluteal artery could supply the lateral epiphyseal arteries alone. From eight fresh-frozen cadaver pelvic specimens we were able to inject the vessels in 14 hips with latex moulding compound through either the medial femoral circumflex artery or the inferior gluteal artery. Injected vessels around the hip were then carefully exposed and documented photographically. In seven of the eight specimens a clear anastomosis was shown between the two arteries adjacent to the tendon of obturator externus. The terminal vessel arising from this anastomosis was noted to pass directly beneath the posterior capsule of the hip before ascending the superior aspect of the femoral neck and terminating in the lateral epiphyseal vessels. At no point was the terminal vessel found between the capsule and the conjoined tendon. The medial femoral circumflex artery receives a direct supply from the inferior gluteal artery immediately before passing beneath the capsule of the hip. Detailed knowledge of this anatomy may help to explain the development of avascular necrosis after hip trauma, as well as to allow additional safe surgical exposure of the femoral neck and head.

Abstract

The purpose of this study was to determine the prevalence of patients at risk for osteoporosis and fracture in a cohort of orthopaedic trauma patients and to subsequently determine the efficacy of a protocol for evaluation, education, and treatment in these patients.Prospective study of "osteoporosis protocol" for evaluation, education, initiation of treatment, and 1-year follow-up in orthopaedic trauma patients.Level 2 regional trauma center.Two hundred sixty consecutive adult patients treated by an orthopaedic trauma surgeon for an acute orthopaedic injury were prospectively enrolled in an osteoporosis protocol between January and August 2005.Patients were evaluated using quantitative ultrasound (QUS) of the heel administered at the bedside and with comprehensive medical, osteoporotic, ovarian, nutritional, family, and current injury histories. For patients identified as high risk for osteoporosis (QUS of the calcaneus-derived T-score

Abstract

Soft tissue injury occurs when using a piriformis portal for femoral nailing. Standard trochanteric portals also can injure the gluteus medius and external rotator tendons, which may be a source of hip pain after nailing. On the lateral facet of the greater trochanter, a "bald spot" may exist that is devoid of tendon insertion. This may be a potential portal for intramedullary nail insertion. We defined the dimensions and location of this region. Cadaveric specimens were dissected to expose the tendon insertions on the greater trochanter. A computer navigation system was used with a stylus and bone morphing to determine the tendon insertions and bald spot anatomy. The greater trochanteric bald spot is covered by the subgluteus medius bursa and has no tendon insertions. Its center lies 11 mm distal to the tip of the greater trochanter and 5 mm anterior to the midline. The shape is ellipsoid with a diameter of 21 mm. This region is large enough to accommodate the size of most nailing system reamers without tendon footprint infringement. Use of this modified entry site may reduce soft tissue injury with nailing procedures and minimize subsequent hip pain.

Abstract

To evaluate the results in patients with open AO/OTA type C3 pilon fractures with segmental bone loss who were treated with a standard treatment protocol.Retrospective case series.Level I trauma center.Of 117 acute open type C pilon fractures treated during the study period, 10 patients with AO/OTA type C3 fractures and segmental metaphyseal bone loss were amenable to treatment with a standard protocol.All patients were treated with immediate debridement and external fixation (stage 1). After a delay of 1-3 weeks, patients with a healthy-appearing soft tissue envelope and no sign of infection underwent open reduction, plate fixation, and antibiotic bead placement (stage 2). Several months later, planned bone grafting was performed (stage 3).The complication rate, additional procedures, and time to bony union were determined.The treatment protocol was able to be completed in all 10 patients. No cases of acute infection or wound necrosis after plate fixation and antibiotic bead placement occurred. Two cases of late infection occurred after delayed bone grafting, one of which was successfully treated and the other resulted in amputation. Nine of the 10 patients healed at an average of 24 weeks.Limb salvage in the most severe open pilon fractures is difficult. In patients with benign soft tissues at several weeks after temporary external fixation, open reduction, antibiotic bead placement, and a delayed bone grafting procedure are associated with a low complication rate and predictable fracture healing.

Abstract

Open wounds occur with calcaneus fracture from direct application of force and from tearing along the medial side of the fracture as the tuberosity displaces laterally. Secondary soft tissue injury can also occur from pressure of the displaced fracture fragments. Tongue-type fractures of the calcaneus lead to variable amounts of displacement of the posterior tuberosity. This displacement may threaten the posterior soft tissue envelope. Because many calcaneus fractures are splinted initially and immobilized for several weeks until swelling resolves, failure to acutely recognize the potential for posterior skin breakdown may lead to severe soft tissue morbidity. The purpose of this study was to determine the incidence of posterior skin involvement in tongue-type calcaneus fractures and to determine the patient and fracture characteristics that lead to high-risk situations.University level I trauma center.All tongue-type calcaneus fractures treated at 1 institution between 2002 and 2007 were identified from a trauma registry. Of 954 patients with calcaneal fractures, 139 tongue-type calcaneus fractures in 127 patients formed the study group.Patient demographics, comorbidities, injury mechanism, fracture displacement, and time to presentation were evaluated. Those injuries that were associated with posterior, secondary soft tissue breakdown were identified and compared to those without breakdown.Univariate analysis and stepwise multinomial logistic regressions were used to identify significant predictors of posterior soft tissue compromise.Twenty-nine fractures (21%) had some degree of posterior skin compromise at presentation, including 12 with threatened skin, 10 with partial thickness breakdown, and 7 with full thickness breakdown. Six soft tissue coverage procedures and one amputation resulted. Patients with posterior skin compromise were less likely to have a fall mechanism (P = 0.001), had significantly greater fracture displacement (P = 0.007), were more likely to smoke (P = 0.039), and were more frequently referred on a delayed basis (P = 0.007). Those with threatened posterior skin who were treated emergently with percutaneous reduction did not progress to soft tissue compromise.A high incidence (21%) of posterior skin compromise occurs in tongue-type calcaneus fractures. These should be treated with immediate reduction, plantarflexion splinting, and close monitoring. Although mechanism, displacement, and time to presentation were significantly correlated with posterior skin involvement, the surgeon should be aware of this potential complicating factor in all tongue-type fractures.

Abstract

Displaced intra-articular fractures of the glenoid are rare and frequently result from high-energy injuries. Types IV, V, and VI fractures have in common a fracture line which extends medially into the scapular body. These fracture patterns present unique challenges for surgical approaches and reduction and fixation strategies. A modified posterior approach allows for the simultaneous exposure of the medial scapular border and the glenoid articular surface. An initial reduction of the medial fracture indirectly restores the scapular relationship, allowing for subsequent completion of the articular reduction via a limited approach to the posterior shoulder using the same incision.

Abstract

Although malunion of proximal tibial metaphyseal fractures are not infrequent, nonunion of the proximal tibia is rare. These nonunions can present particular challenges in management, such as malalignment, a short proximal segment, and soft tissue compromise. Few treatment guidelines and long-term outcomes are available. The purpose of this study was to determine the long-term functional outcomes of patients treated with open reduction and internal fixation.Sixteen patients with a proximal tibial nonunion were treated between 1992 and 2005. Five fractures were originally open injuries, but all were aseptic at the time of definitive fixation. All nonunions were treated with a consistent approach of debridement, deformity correction, lateral plating, tensioning and compression, lag screws and bone grafting. Patients were reviewed radiographically and with a Knee Society questionnaire at a mean follow-up of 39 months (range 10-113 months).All nonunions healed at an average of 4 months, and alignment was within 5 degrees of anatomic in all cases. Knee Society function and knee scores improved significantly, to 87.4 and 89.4, respectively (P < 0.05 for both). Functional outcomes were excellent overall. Fourteen of the patients (88%) subjectively returned to their previous activities and were satisfied with their result.Using an algorithmic approach of dbridement, deformity correction, lateral tension band plating with compression, and rigid stabilization, fracture healing and functional outcome can be reliably restored in these difficult fractures.

Abstract

Associations between fracture patterns are important and can ensure proper diagnosis and guide treatment. Occult posterior malleolus fractures associated with distal spiral tibia fractures often are underrecognized and the morbidity of a missed posterior malleolus injury can be substantial. We determined the association between the two injuries and evaluated the ability of a new protocol to improve management of these associated fractures. Of 62 consecutive patients with fractures of the distal third of the tibia, we retrospectively evaluated the first 39 patients and prospectively used a diagnostic protocol including computed tomography of the ankle in the subsequent 23 patients. The minimum followup was 3 months (mean, 25 months; range, 3-68 months). Twenty-four patients (39%) had fractures of the posterior malleolus. Before initiation of the protocol, intraarticular fractures were recognized in 33% (with one delayed diagnosis and one missed diagnosis), and after institution of the protocol, the detection rate was 48% with no known missed injuries and complete followup; however, with the limited power the detection rates were similar without and with the protocol. A spiral distal tibial shaft fracture with a proximal fibula fracture should alert the surgeon to investigate an occult ankle injury, particularly of the posterior malleolus. A protocol including computed tomography of the ankle may detect more injuries in a larger study.Level II, prognostic study.

Abstract

The use of inferior vena cava (IVC) filters for prevention of pulmonary embolism (PE) in high-risk trauma patients is well accepted. High rates of recurrent venous thrombosis, however, and postthrombotic syndrome (PTS) have been reported in nonsurgical patients with medical comorbidities. Patients with pelvic trauma and thromboembolic disease have a unique thrombogenic pathophysiology, and the long-term consequences of filter placement in these patients are unknown. We sought to evaluate the outcomes of patients who sustained pelvic trauma, and who developed venous thrombosis and were treated with a vena caval filter.A cohort of 102 consecutive patients was treated for a pelvic or acetabular fracture who developed deep vein thrombosis (DVT) preoperatively and had a caval filter placed. Thromboembolic events and complications were evaluated by both retrospective chart review and a prospective questionnaire. Eighty-eight patients (86%) returned the questionnaire at an average follow-up of 4 years.No patients were readmitted to the hospital for recurrent venous thrombosis or PE. Six patients (7%) described new swelling in the lower extremities, and one (1%) demonstrated evidence of PTS. No deaths occurred related to PE.The use of IVC filters appears to be safe and effective in preventing PE in patients with pelvic trauma and established venous thrombosis. The risk of recurrent DVT is low and PTS is negligible in these patients. Filter placement use is not associated with the same long-term complications as in patients with thrombosis because of chronic medical comorbidities.

Abstract

Navigation procedures rely on the stability of the reference arrays (RA) fixed to the bony anatomy. The risk of inadvertent collision and unnoticed movements of the RA may occur, and limb movements might also provocate collisions. Consequently, relevant measurements failures during the navigated procedure might occur and reduce the overall precision of the system. The magnitude of torque to destabilize an RA from its bony-fixation is unknown. The purpose of this study was to determine the ability of standard RA's to resist applied torque. A digital torque application device was developed to allow for precise torque application to the RA system at four cadavers. Clockwise, gradually increasing rotational force was applied to the RA in 1, 2, or 3 Nm, held for 1 s and released, repeated in 10 cycles. One pin fixation systems with 4.0 Schanz pins were used. A second RA was fixed 20 cm proximal to the tested RA. A navigation system was used to measure the relative positions of both RA's during torque application. The rotational differences at torque application were calculated and statistically evaluated. Results revealed averaged 1.0 degrees rotation [range (r), 1.0-1.1 degrees ] with first cycle of 1 Nm torque, the last cycle averaged 1.0 degrees (r, 1.0-1.1 degrees ) with no significant differences in rotation between any of the cycles (p > 0.5). Torque of 2 Nm resulted in 1.8 degrees rotation (r, 1.5-1.8 degrees ) with no significant increases between first and second cycle (p = 0.56), second and third trials (p = 0.35) while fourth cycle averaged 2.0 degrees , with significant increase (p = 0.011). All subsequent cycles resulted in significant increases. Torque of 3 Nm produced 2.9 degrees of rotation for initial cycle (r,2.5-3.3 degrees ), with significant increases with each cycle (p < 005). Torques of > or =2 Nm may cause loosening of the RA, thus may lose its original position relative to the bone. Surgeons using computer aided surgery systems should be aware of possible unrecognized movements of the RA, however, gentle collisions do not appear to cause significant motion or destabilization.

Abstract

Intraoperative two-dimensional (2D) fluoroscopy of acetabular fractures is difficult due to the complex three-dimensional (3D) anatomy. Intraoperative 3D fluoroscopy may have particular utility in the evaluation of acetabular fractures. We compared the accuracy of 3D fluoroscopic imaging in evaluating acetabular fracture displacement and implant placement with fluoroscopy and computed tomography (CT) scans.In 24 cadaveric acetabuli, a transverse acetabular fracture was created. First a 2 mm step-off of the articular surface was created and reconstruction plates placed on the anterior and posterior columns. In 12 specimens, two screws were placed intraarticularly, protruded by 2 mm. In the remaining 12 specimens, the same constructs were used but the screws remained extraarticular. Second tests were designed to simulate an impaction injury. After hardware removal, a hollow trephine (diameter of 14.9 mm) was used to core a bone cylinder on the dome of the acetabulum, and impacted until it was recessed into the articular surface by 2 mm. Plates were placed, and screws were placed intraarticularly in 12 specimens, as in the first set of tests. All cadavers were imaged with standard 2D-, 3D fluoroscopy and CT. Three observers randomly evaluated all imaging studies for all specimens.For detection of intraarticular screws, both the Iso-C3D and the CT scans were significantly more sensitive (96 and 96%, respectively) and specific (96 and 100%, respectively) in detecting the intraarticular position compared to 2D fluoroscopy (75%; P < 0.05). Sensitivity of articular step-off detection was no different between the Iso-C3D (83%), CT (79%), and 2D fluoroscopy (87%). Articular impaction was correctly identified in 79% of specimens with the Iso-C 3 D technique, while the CT was accurate in 92%. 2D fluoroscopy was accurate in 62% for the impactions (P < 0.05 vs. CT).3D-fluoroscopic imaging appears to be extremely accurate in evaluating acetabular fracture constructs. Its sensitivity and specificity for evaluating intraoperative hardware was greater than with 2D fluoroscopy and equivalent to CT scan. Volumetric impactions were also reliably demonstrated on both of the 3D modalities, which were both superior to 2D fluoroscopy. Overall, Iso-C3D multiplanar imaging yields information regarding implant placement and articular reduction that is more detailed and accurate than standard fluoroscopy and is comparable to CT.

Abstract

Fracture repair is influenced by the mechanical environment, particularly when cyclic loads are applied across the fracture site. However, the specific mechanical loading parameters that accelerate fracture healing are unknown. Intact bone adaptation studies show enhanced bone formation with pauses inserted between loading cycles. We hypothesized pause-inserted noninvasive external loading to mouse tibial fractures would lead to accelerated healing. Eighty mice underwent tibial osteotomies with intramedullary stabilization and were divided into four loading protocol groups: (1) repetitive loading (100 cycles, 1 Hz); (2) pause/time-equivalent (10 cycles, 0.1 Hz); (3) pause/cycle-equivalent (100 cycles, 0.1 Hz); and (4) no load control. Loading was applied daily for 2 weeks. Healing was assessed using histology, biomechanical bending tests, and microcomputed tomography. The pause-inserted, cycle-equivalent group had a greater percentage of osteoid present in the callus cross-sectional area compared with no-load controls, indicating more advanced early healing. The pause-inserted, cycle-equivalent group had a failure moment and stiffness that were 37% and 31% higher than the controls, respectively. All three loaded groups had smaller overall mineralized callus volumes than the control group, also indicating more advanced healing. At an early stage of fracture healing, pause-inserted loading led to more histologically advanced healing.

Abstract

Traditionally, both high- and low-energy tibial plateau fractures are classified on the basis of the anteroposterior (AP) plain radiograph. Several fracture types exist that are not included in currently used classification schemes, including posteromedial shear and coronal plane fractures. These fracture types can appear as isolated fracture lines or as a part of a bicondylar plateau fracture. The purpose of this study is to describe a posteromedial supine surgical approach and antiglide plating of the posteromedial fragment, either as a single approach for a unicondylar posteromedial fracture or in combination with a second lateral approach for bicondylar fractures. We have used this technique in 27 patients that had posteromedial shear fractures on preoperative computed tomography (CT) scans, in the setting of a Level I trauma center. Ten were isolated medial plateau fractures, and 17 had bicondylar fractures. Radiographic analysis was done for all patients, and clinical outcomes were available in 19 out of 27 patients through phone interviews and chart reviews. Mean follow-up was 3.5 years (range 1-12 years). Seventy-five percent of patients had anatomic or good reductions. The average Oxford knee score was 19.9 +/- 5.4 (12-29). Average range of motion was 0 to 120 (0-90 to 0-130). The articular malreduction (>5-mm gap or step-off) rate was 4%, and there were no wound complications. Posteromedial shear fractures of the tibial plateau are not uncommon. This pattern is assessable using the preoperative CT scan. A supine posteromedial approach with antiglide plating provides a good clinical solution for these complex injuries.

Abstract

To evaluate and compare the accuracy of using the femoral neck axis and the greater trochanter with navigation to determine femoral anteversion.Eight human femora with midshaft fractures were used. Real anteversion (AV) values were first measured on a movable fixation system, with digital images imported to software. Second, a navigation system determined the femoral AV with fluoroscopic images of hip, fracture site and femoral condyles. AV I: the centre of the femoral head to the femoral neck axis, the lateral distal femoral condyles and the distal fragment were marked. AV II: the centre of femoral head to the centre of the greater trochanter was marked by the same method.Actual femoral AV ranged from 1.0 degrees to 9.0 degrees . Head-neck landmarks revealed a mean difference of 1.4 degrees . The greater trochanter-femoral head landmarks revealed a mean difference of 0.3 degrees , significantly less than the head-neck measurements.Compared with the reliable methods of determining femoral rotation postoperatively, intraoperative measurement is difficult. We found that the centre of the tip of the greater trochanter is easier to identify than the centre of the femoral neck and gives more precise results. This requires analysis of the contralateral limb, which may be feasible with newer non-invasive registration methods.

Abstract

Antegrade or retrograde intramedullary nailing is a common and well established procedure for the treatment of femoral shaft fractures. One drawback of this technique is the high incidence of clinically relevant malalignment. Despite intra-operative and radiological improvements this problem has not yet been solved efficiently. The aim of this study was the evaluation of the mechanical influence on the antetorsion angle of intramedullary nails during and after interlocking in femoral shaft fractures.A mechanical instrument was developed allowing a defined torque to be administered to the distal femur fragment. As an optical measurement system for the assessment of the antetorsion angle, a navigation system was applied. Initially the influence of the interlocking mechanism of the nail on the antetorsion deviation was investigated. The distal interlocking hole was fixed free handed or by using a navigation system. The multidirectional movement of the distal femur fragment was documented. Furthermore, the influence of the rotational stability on the antetorsion angle after mechanical stress of 4 NM was investigated by measuring the remaining rotational capacity of the distal femur fragment.The average remaining rotational capacity of the distal femur fragment was 5.8 degrees after locking the nail by hand. The navigated locking resulted in a deviation of only 2 degrees , a significant difference compared to the free-hand procedure. The rotational stability under stress showed an average of 15.4 degrees deviation of the distal fragment. Even after complete interlocking of the intramedullary nail a 14.2 degrees rotational deviation was observed.It could be shown that mechanical stability as well as the interlocking itself of femoral nails have a relevant impact on the antetorsional angle of the femur. Potential sources of error of the femoral antetorsion angle can be caused by the interlocking process as well as by forced rotation of the femur after interlocking. Clinical studies are needed to improve our findings, while the observed effects might have an essential influence on the incidence of femoral malalignment after osteosynthesis by intramedullary nailing of the femur.

Abstract

Displaced acetabular fractures are best treated with open reduction to achieve anatomic reduction and maximize the chance of a good functional outcome. Because of the anatomic complexity and often limited visualization, fracture reduction can be difficult. Virtual planning software can allow the surgeon to understand the fracture morphology and to rehearse reduction maneuvers. The purpose of this study was to determine the effect of a novel virtual fracture reduction module on time and accuracy of reduction. Four acetabular fracture patterns were created in synthetic pelves, which were implanted with fiducial markers and were registered with CT scan. Ten surgeons used virtual fracture reduction software or conventional 2D planning methods and immediately reduced the fractures blindly in a viscous gel medium. 3D imaging was again performed and the accuracy of reduction was assessed. The average malreduction was significantly improved following planning with the virtual software compared to the standard technique. The time taken for reduction was also significantly less for two of the four fracture patterns. Virtual software may be useful for visualizing and planning treatment of fractures of the acetabulum, potentially leading to more accurate and efficient reductions, and may also be an effective educational tool.

Abstract

Successful outcomes following high tibial osteotomy (HTO) require precise realignment of the mechanical axis of the lower extremity. The inability to accurately assess the weight-bearing axis intraoperatively may account for inappropriate degrees of correction with the osteotomy. We tested the hypothesis that axial loading of the limb affects alignment during an HTO procedure. A custom mechanical load apparatus was developed to simulate weight-bearing conditions intraoperatively. Fixation to the trunk was achieved by supraacetabular pins and an external fixation device, which allowed the pelvis to be rigidly fixed relative to the apparatus while axial load was applied to the foot. Ten fresh cadavers were used for testing. The baseline mechanical axis was determined by a navigation system. HTO was then performed, and varying degrees of valgus correction were obtained and stabilized. For each correction, one quarter, one half, or full body weight was applied axially to the foot, and the axis deviation was measured. Subsequently, the MCL was sequentially released to determine the effect of ligament incompetence. Prior to osteotomy, load application did not produce significant axis deviations. Following osteotomy, the mechanical axis deviation shifted significantly in all trials, increasing as load magnitude and degree of correction increased. With complete sectioning of the MCL, a further significant shift in the axis occurred. Deviations of mechanical axis occur on weight bearing in lower limbs following HTO. These shifts must be considered and possibly quantified to achieve the desired axis correction and maximize the chance at a successful long term outcome.

Abstract

Fractures of the proximal humerus, particularly in osteoporotic bone, are still frequently referred to as unsolved fractures. The recent explosion of locking plate technology has included these fractures, but it appears that laterally placed locking plates may not be as predictable as hoped. Medial column mechanical support of these fractures may play a significant role in the ultimate stability of fixation during rehabilitation until healing occurs. We have devised a technique of using a segment of fibula allograft, placed endosteally and incorporated into the locking construct, to aid in the reduction and restoration of the mechanical integrity of the medial column of the proximal humerus.

Abstract

Because of the relatively large surface area of metaphyseal cancellous bone, the majority of distal femur fractures heal reliably. Nonunions of the distal femur do rarely occur, however, and the associated bone loss and soft tissue scarring can make successful treatment difficult. Few reports in the literature exist regarding the clinical and functional outcome after treatment of distal femoral nonunions. The purpose of this study was to evaluate the outcome of patients who underwent treatment of a distal femoral nonunion using a standardized treatment plan that included open reduction, internal fixation, supplemental bone graft, lag screw placement, and arthrolysis.Thirty-one patients with a distal femoral nonunion were treated by a single surgeon from 1992 to 2002, and their clinical and radiographic outcomes were assessed. The average age was 57.6 years, and four patients (13%) had sustained open fractures. The average time from injury to diagnosis of the nonunion was 15.9 months and the average time of follow-up was 41.5 months after the definitive nonunion surgery. In all cases a fixed-angle implant was used. Lag screw and bone graft augmentation was used in all patients; 71% received iliac crest bone graft and 29% received demineralized bone matrix. Outcomes were analyzed using radiographs and the Knee Society Rating Score (KSRS).At final follow-up the union rate was 97%, and the average time to heal was 15.9 weeks. A complete return to preinjury functional status was achieved in 84%. The KSRS Knee Assessment subsection score improved from 43.0 to 78.3 after surgical treatment of the nonunion (p < 0.001). The KSRS Knee Function subsection score also improved from 11.1 to 61.2 at final follow-up (p < 0.001).Distal femoral nonunions may be treated successfully with correction of deformity, stable fixed-angle internal fixation, lag screw placement, and supplemental bone grafting. Knee joint manipulation and arthrolysis are important components of the treatment plan if knee motion is limited because of fibrosis. This yields predictable functional outcome after the surgical intervention.

Abstract

Displaced and unstable fractures of the proximal humerus are notoriously difficult to manage. Successful surgical treatment requires finding the appropriate balance between adequate exposure for reduction and rigid fixation and minimizing soft tissue dissection. The anterolateral acromial approach was developed to allow less invasive treatment of proximal humerus fractures. The plane of the avascular anterior deltoid raphe is utilized, and the axillary nerve is identified and protected. Anterior dissection near the critical blood supply is avoided, substantial muscle retraction is minimized, and the lateral plating zone is directly accessed. Over a 4-year period, 52 patients with acute displaced fractures of the proximal humerus were treated with the anterolateral acromial approach and either a locking plate or an intramedullary nail. Twenty-three patients were evaluated clinically at a minimum follow-up of 1 year (average, 28 months) by clinical examination for range of motion and nerve function and a QuickDASH score. There were no axillary nerve deficits postoperatively related to the approach, and the average QuickDASH score was 25.2 (0, best; 100, worst). This approach allowed direct access to the lateral fracture planes for fracture reduction and plate placement or safe nail and interlocking screw placement.

Abstract

The purpose of this study was to determine the area, dimensions, and orientation of the gluteus medius footprint to provide an improved understanding of its insertional anatomy.Eight fresh-frozen cadaveric hips were dissected, leaving only the most distal gluteus medius tendon attached to the greater trochanter. The tendon insertion footprint and proximal femur were digitized and mapped by use of 3-dimensional computer navigation software. The area, location, and dimensions of the tendon insertion were determined.The gluteus medius tendon has 2 distinct insertion sites on the greater trochanter, the lateral facet and the superoposterior facet. The mean areas of insertion onto the lateral and superoposterior facets were 438.0 mm2 (SD, 57.7 mm2) and 196.5 mm2 (SD, 48.4 mm2), respectively. The lateral facet footprint had a mean longitudinal dimension of 34.8 mm (SD, 4.3 mm), was angled at a mean of 36.8 degrees (SD, 6.7 degrees ) relative to the long axis of the femur, and had a mean minimum width of 11.2 mm (SD, 1.8 mm). The superoposterior facet's shape approximated that of a circle, with a mean diameter of 17 mm (SD, 2.0 mm).The gluteus medius tendon has 2 distinct and consistent insertion sites onto the greater trochanter. This information will provide surgeons with a better understanding of the footprint anatomy when evaluating gluteus medius tendon tears.Gluteus medius tendon tears can be a source of significant pain and morbidity. This study describes the anatomic morphology of this tendon insertion, which should aid in its repair when necessary.

Abstract

Intramedullary nails for fixation of extracapsular hip fractures have gained popularity recently. Although clinically successful, they are not devoid of complications. An infrequently reported complication is the medial migration of the femoral neck element (FNE) of the implant into the pelvis. The purpose of this study was to create a biomechanical model simulating this effect based on a clinical case radiographic analysis.Eight clinical cases of medial migration were available for radiographic analysis. Medial migration was quantified and the fractures were classified. A biomechanical model was built comprising two fixtures containing the nail and FNE respectively. A pivot between the two fixtures, representing a deficient femoral calcar, simulated an unstable fracture type. Two pivot points were used for each nail. The constructs were tested using sinusoidal loading (40-800 N at 2 Hz) and medial migration was assessed. Five different nail designs (TFN, PFN, PFN-a, Gamma-3 and IMHS) were tested (overall 75 tests).All the five implants demonstrated medial migration to a similar distance. The TFN required the highest number of cycles (3127 +/- 2569) and the IMHS the lowest (58.8 +/- 3.6) although this difference did not reach statistical significance (P = 0.07). Changing the pivot point for the medial calcar did not alter the results significantly. All eight clinical cases demonstrated an unstable intertrochanteric fracture pattern (AO/OTA 32A2).Discrete biomechanical conditions are required to reproduce medial migration of the FNE in cephalomedullary devices.

Abstract

Rotational deformity following intramedullary nailing of femoral shaft fractures is a clinically significant and underdiagnosed problem. Intraoperative determination of rotation is difficult and may be caused by several factors. The insertion of interlocking screws at a slightly oblique angle may cause a substantial degree of rotational deformity, and this factor has not been evaluated as a cause of malrotation.In eight paired cadaveric femurs, a midshaft transverse fracture was created and an antegrade nail was placed. The specimens were placed in a custom jig which allowed free rotation of the distal segment. Distal interlocking was performed using either a freehand technique or with navigation, and femoral anteversion was measured before and after interlocking to determine the change caused by the interlocking screw.Freehand placement led to rotational shift up to 7 degrees (mean, 5.8 degrees ; range, 4-7 degrees ), and navigated insertion led to a change of 2.0 degrees (range, 1-3 degrees ; p<0.05). In addition, drill-nail contact and a visible shift of the fracture site occurred in all freehand trials, whereas in the navigation group, contact occurred in only one trial without fracture movement.Freehand distal interlocking may be a substantial cause of rotational deformity, and the assistance of computer navigation systems may improve this malrotation.

Abstract

The mechanical environment at a fracture site can influence the course of healing. Intermittent parathyroid hormone (PTH) has been shown to accelerate fracture healing. Intact bone models show that mechanical loading and PTH have a synergistic beneficial effect on osteogenesis. We hypothesized that PTH and mechanical loading would have a similar synergistic effect on fracture healing. Eighty mice underwent surgical osteotomy and intramedullary nailing of the tibia. The mice were divided into four groups: one underwent daily loading, one received daily subcutaneous PTH injections (30 microg/kg/day), one received both loading and PTH, and a control group received sham loading and vehicle injection. Daily loading was applied to the ends of the tibia with an external loading device for 2 weeks. Fracture healing was assessed by microcomputed tomography, histology, and biomechanical testing. The group with both loading and PTH had increased osteoblast and osteoclast activity and was the only group with a significantly larger callus mineral density and bone volume fraction. The PTH only group had significantly more osteoid in the callus compared to the control group, indicating enhanced early osteoblast activity. This group also had a significantly higher bone mineral content and total bone volume compared to controls. The group that received loading as the only intervention had significantly greater osteoclast activity versus controls. The contribution of loading and PTH administration to the fracture healing cascade indicates a synergistic effect. This finding may be of potential clinical utility when weight bearing is utilized to stimulate lower extremity fracture healing.

Abstract

Anatomic reconstruction of the posterior calcaneal facet after intra-articular fracture is one of the critical factors in achieving a good functional result. Intraoperative evaluation of fracture reduction and implant placement relies on direct view by standard fluoroscopy. We hypothesized that three-dimensional (3D) fluoroscopy is more accurate than conventional fluoroscopy, and equivalent to CT for determining fracture reduction and screw position in calcaneal fractures.A Sanders type IIB fracture pattern was created in eight embalmed lower extremity cadaver specimens. First, the posterior facet was reduced with a step-off of 0 mm to 2 mm in 0.5-mm increments. All specimens had two dimensional (2D) fluoroscopy, 3D fluoroscopy with an Iso-C3D, and a CT scan. Next, screws were placed so they protruded into the subtalar and calcaneocuboid joint and through the medial wall. All specimens were imaged again. Three observers evaluated all imaging studies, and the sensitivities and specificities of each modality were determined.Both the Iso-C3D and the CT were more specific for anatomic reduction (75% and 100%, respectively) than fluoroscopy (62%). For the malreduced trials, the Iso-C3D and CT were both 100% sensitive, and the sensitivity of fluoroscopy was 63% (p < 0.001 for both). For the intra-articular screws, the Iso-C3D and CT were accurate in all cases (sensitivities = 100%), and fluoroscopy was accurate in five of the eight trials for both joints (sensitivities = 63%). Finally, with screws protruding through the medial wall, the sensitivity of fluoroscopy was 25%, for the Iso-C3D 88% (p = 0.02), and for CT was 100% (p = 0.003).Three-dimensional fluoroscopic imaging is more accurate than 2D fluoroscopy for detection of intra-articular incongruities and implant position and is similar to CT.This new technology may be particularly useful in assessing calcaneal fractures and may lead to improved fracture reduction, less implant misplacement, and improved patient outcomes.

Abstract

The difficulty in assessing femoral rotation during intramedullary nailing is well-established. Navigation systems allow the surgeon to detect and set the version of the injured leg at the desired angle. We report the first cases of navigated femoral nailing using noninvasive registration of the contralateral uninjured leg to determine the patient's anatomy. This allows the desired femoral rotation, which is that of the healthy femur, to be statically locked to precisely match the contralateral limb.

Abstract

Intertrochanteric hip fractures have become more common as the elderly population continues to increase, and surgical stabilisation of these fractures remains a persistent challenge. The purpose of this study was to analyse the ability of a new helical blade device to stabilise intertrochanteric hip fractures, and to further determine which factors are important in implant stability.Two hundred and fifty-five patients with an intertrochanteric hip fracture were treated with a trochanteric fixation nail (TFN), 97 of whom fit strict radiographic and follow-up criteria and were included in the study group. After adjusting for magnification and rotation, blade migration within the femoral head and telescoping of the blade along its axis were measured using a custom-designed grid system. Multivariate regression analyses were performed to determine which variables predicted blade migration and telescoping.Fifty-nine fractures were classified as stable, and the remaining 38 were unstable. Mean telescoping was 4.3 mm in the unstable group, compared to 2.6 mm in the stable group (p<0.05). Blade migration within the femoral head averaged 2.2 mm overall, with no difference between stable and unstable fractures. For both telescoping and blade migration, no significant change occurred after the 6-week time point in the stable or unstable group. Nail length, age, and gender did not have a significant effect on either blade migration or telescoping implant position change. Of the initial cohort of 255 patients, five cutouts and one nonunion occurred, three of which required subsequent procedures.Subtle migration ( approximately 2mm) of the tip of the blade within the femoral head occurred in all fractures, but this did not preclude maintenance of reduction and fracture healing, and was not predicted by fracture type, reduction quality, age, or gender. More telescoping occurred in unstable compared to stable fractures, but this averaged 4mm and did not affect stable fixation or fracture healing. All position changes occurred within the first 6 weeks postoperatively, with no subsequent detectable migration or telescoping. Clinical correlations will be needed in the future to determine the significance of small amounts of migration or differences in telescoping, but this device appears to provide effective fixation in both stable and unstable intertrochanteric hip fractures.

Abstract

Staphylococcus aureus infection is a serious complication in patients receiving orthopaedic implants. Treatment with antibiotic-loaded cements can deliver high local concentrations and reduce toxic side effects associated with systemic antibiotic administration, but polymethylmethacrylate cement is nondegradable and may necessitate additional surgery for removal. Previous studies provide support for hydroxyapatite as a biodegradable carrier, but consensus has not been achieved. We hypothesized vancomycin-loaded hydroxyapatite was superior to vancomycin-loaded polymethylmethacrylate in reducing the number of bacterial colony-forming units in the setting of osteomyelitis. Osteomyelitis was induced in rats using an established model. Animals then were randomly assigned to a control group (no antibiotics), a group treated with vancomycin-loaded polymethylmethacry-late, and two groups treated with hydroxyapatite loaded with either low-dose or high-dose vancomycin. After 6 weeks we compared the number of colony-forming units per gram of harvested bone between groups. Vancomycin-loaded hydroxyapatite was inferior to vancomycin-loaded polymethylmethacrylate in reducing the number of bacterial colony-forming units and vancomycin-loaded polymethylmethacry-late was superior to the control group. We observed no difference between low- and high-dose vancomycin-loaded hydroxyapatite groups. The poor handling properties of hydroxyapatite paste may explain these findings. Based on these results, a hydroxyapatite carrier cannot be recommended for the treatment of osteomyelitis.

Abstract

Displaced fractures of the proximal humerus remain particularly difficult to treat. Because of the poor quality of cancellous bone, it seemed that locking plates would be ideally suited for fixation in this region. However, as clinical reports begin to become available, it appears that these plates are not a panacea for these fractures and may be associated with a high complication rate. Coupled with the generally poor long-term outcomes of hemiarthroplasty, new fixation methods must be sought. Several technical factors, techniques, and alternative approaches have recently been described as possibly improving fixation stability in these fractures. Specifically, the anterolateral acromial approach, which avoids vascularity exposure, allows direct access to the lateral plating zone, and minimizes soft-tissue dissection, may be useful. Mechanical support of the medial column when anatomic cortical contact is not possible is also critical to maximizing stability. This may be achieved either with purposeful inferomedial humeral head screws or endosteal fibula allograft augmentation.

Abstract

Up to now, the use of navigation systems for the placement of scaphoid screws has been impossible, mainly because there have been no ways of fixing the reference markers. Faulty placement rates in internal fixation of the scaphoid show there is a current need for a 3D image-based navigation system and intraoperative monitoring of how successful the procedure will be. For this reason, we have developed a new radiotransparent hand fixation device (Scaph-Splint), which allows reliable and accurate drilling of the scaphoid using 3D navigation. Tests of this device and the simultaneous precise placement of screws securing an internal fixation device are described in this paper.Relative movements between the wrist and fixation device were measured with a 3-D ultrasound motion analyser system. Five cadaveric upper extremity specimens were then used for further navigated test applications. Each specimen was placed in the fixation device, and both the forearm and hand were secured to the two surfaces, with the wrist in approximately 80 degrees of extension. A reference marker was then securely fixed to the fixation device. A commercial navigation system and 3-D fluoroscopic imaging were used for each trial. Under navigation, the scaphoid was drilled in retrograde fashion, and a screw was placed into the drilled hole. Following screw placement, a 3D scan was performed to evaluate its position. The screw placement was analysed blindly to optimal placement and drill or screw perforation, and the image quality was rated on a visual analog scale (VAS).There were few artefacts, and the image quality of the 3-D scan was judged as as good (VAS 79). Deviations of >or=0.2 mm between planned trajectory and drilling tunnal were not found in any of the specimens; there were deviations of >or=1 mm in one case, and all other cases showed deviations of

Abstract

To assess the wound complications and reductions achieved in a cohort of patients with pilon fractures who were treated using a novel lateral approach.Retrospective review.Two level 1 trauma centers affiliated with academic institutions.All 44 fractures (in 43 patients) treated by the senior authors with open reduction and internal fixation (ORIF) using the lateral approach as the primary approach were included.Data regarding medical comorbidities, mechanism of injury, soft-tissue injury sustained during the injury, treatment, wound healing, and secondary surgeries were recorded. Fractures were classified using the AO/OTA system with most being type C3. Eighteen fractures were open injuries (10 type 3). Fracture reductions were scored using the criteria of Teeny and Wiss.Quality of articular reduction and soft-tissue healing.An anatomic or good fracture reduction was achieved in 41 fractures (93%), and a fair reduction was obtained in 3 fractures. Two patients were successfully treated for deep infection (4.5%), and 2 patients developed a wound dehiscence (4.5%). There were no amputations. Twelve patients underwent secondary surgeries (27%). Five of these were for symptomatic screw removal (related to the fibular hardware in all cases), and the sixth was for planned removal of a syndesmotic-type screw (13.6%). Four were for nonunion, representing 9% of all cases. The remaining secondary surgeries (2 cases) were performed for infection. Overall, 13.6% of patients underwent a secondary surgical procedure to address nonunion or infection.When applied in a staged fashion, the lateral surgical approach for pilon fractures provides excellent protection of the soft-tissue envelopes by creating thick flaps while allowing excellent visualization for reconstruction of the anterior and lateral distal tibia.

Abstract

Inaccurate coronal plane realignment is a common problem after high tibial osteotomy. It has been shown that lower limb rotation has an effect on the two-dimensional measurement of lower limb alignment. Although alignment errors are known to occur due to limb rotation, the magnitude of this effect is unknown. Navigation systems allow for the measurements of coronal plane alignment and dynamically rotational and sagittal plane. Our study evaluated the effect of rotational leg movements on coronal plane alignment as determined by image-free navigation. We hypothesized that a linear relationship exists between rotation and angular measurements. Eight cadavers were used, while three test conditions of the complete lower limbs were established: (1) solid knee arthrodesis, (2) provisional knee arthrodesis and (3) unconstrained knee conditions. Navigated measurements of coronal and sagittal lower limb axis were done initially without knee flexion for defined internal/external rotations of 5 degrees, 10 degrees and maximal values for all test series. Repeated test for the unconstrained knee included stepwise knee flexion of 5 degrees, 10 degrees and 20 degrees. Statistical analysis comparing the test conditions 1, 2 and 3 and comparison between flexion movements of the unconstrained knee were done. Results revealed no significant differences between the different rotations of test condition 1 (mean 0.34 degrees, SD 0.23, range, 0 degrees-0.8 degrees). Condition 2 similarly did not result in significant deviations (mean 0.51 degrees, SD 0.24, range 0.1 degrees-0.9 degrees). Measurement deviations ranging from 0.4 degrees to 4.3 degrees were found for condition 3, the unconstrained knee. However, no statistically different testings from the arthrodesed knee were found (P=0.099-0.410). Knee flexion from 5 degrees, 10 degrees or 20 degrees, showed significant deviations (P<0.05) for all rotations at all degrees of flexion. Rotation and flexion of 5 degrees led to significant alignment errors of 3.4 degrees and 2.8 degrees, respectively, for internal and external rotations. Measurement failures due to the rotational movements of 1 degree-4 degrees might add to additional sources of errors causing relevant under- or over-corrections of the mechanical leg axis. Discrepancies of the axis due to rotational movements as well as flexion of the knee joint can be avoided and corrected immediately with the help of navigation.

Abstract

Pelvic external fixation pins placed in the supraacetabular region, directed posteriorly, and mounted with a femoral distractor as a compressor may impart compression forces across the sacroiliac joint. This would be useful for indirect reduction and stabilization of the posterior pelvis. The purpose of this study was to determine the forces achieved by this construct compared with other forms of fixation.Mechanical study.University laboratory.Synthetic pelvis models.A complete symphyseal and unilateral sacroiliac joint disruption was created in 6 synthetic pelves. Five different fixation constructs were applied, and a pressure-sensitive film (TekScan) was fixed in the sacroiliac joint. Each construct was compressed in a standardized fashion.After maximal compression of each trial, the magnitude and regional distribution of the force was recorded.Standard 2-bar external fixation did not allow for any compression across the sacroiliac joint in any specimen. The pelvic compressor delivered 86.3 N (SD, 12.1 N) of force across the sacroiliac joint when the pins were inserted half way, and 85.8 N (SD, 11.0 N) with full pin insertion. Iliosacral screws led to 145 N of compression on average (SD, 69.9 N), but this was not statistically different from the pelvic compressor groups. A C-clamp generated compression of 206 N (SD, 31.9 N), which was significantly greater than both the pelvic compressor groups (P < 0.005).A simple modification of pelvic external fixation, placing a femoral distractor as a compressor on supraacetabular pins, allows for indirect medial translation of the innominate bone and compression across the sacroiliac joint. The force achieved is less than with a C-clamp, but it is safer, involves techniques familiar to most surgeons, and may be useful in the acute management of unstable pelvic fractures.

Abstract

Computer navigation in orthopaedic procedures can improve accuracy and decrease radiation time compared to traditional fluoroscopy. Many different applications are now available, and drilling is commonly used amongst them. Aside from additional set up time required, the drilling procedure itself may take a significant amount of time. We hypothesised that using an external stabilising guide which can be set anywhere in space can decrease then time necessary for navigated drilling.Foam blocks, 80 mm in length and a density similar to cancellous bone, were obtained. Small discs were placed on one end as drilling targets. Using an Iso-C 3D navigation system, 20 navigated drilling trials were performed under each of two conditions: freehand, and with the use of a drill stabilising guide attached to an operating table. The time and accuracy of the two methods were compared.The time required for the entire navigation procedure was significantly less using the stabilising arm compared to drilling freehand with navigation (4.5 min versus 5.8 min, p=0.009). There was no significant difference in accuracy between the two methods.Using a guide which attaches to the table and allows the surgeon to fix the drill sleeve when the desired vector is chosen allows for faster navigated drilling. This was easy to set up and attach to the table, and did not diminish accuracy of drilling an intended target.

Abstract

Various patterns of ankle fractures that are not accounted for by common classification systems have been the subject of case reports. The first difficulty with these variant patterns is recognizing all associated pathology, followed by the successful application of stable fixation. The purpose of this study was to describe the common morphologic features and ligamentous injuries of a unique variant fracture pattern, as well as the surgical treatment technique and the short-term functional and radiographic outcomes. Of 121 consecutive unstable ankle fractures over a 2-year period, 7 patients were found to have a similar constellation of injuries around the ankle. A vertical shear fracture of the posteromedial tibial rim was the main feature. Six of the 7 also had a fracture of the posterior malleolus. On magnetic resonance imaging, the deltoid and posterior tibiofibular ligaments were intact in all cases. Fractures were treated with open anatomic reduction of the posteromedial and posterior fragments with antiglide plate fixation. All fractures healed at 2 months without loss of reduction, fixation failure, or surgical complications. The average American Academy of Orthopaedic Surgeons lower extremity score was 79 at an average of 8 months' follow-up. The common radiographic and morphologic features associated with this posteromedial fracture indicate that it likely occurs through a common mechanism that involves hyperplantarflexion. The characteristics of this fracture pattern have not been fully described previously, but this ankle fracture variant may occur in up to 6% of cases. Unstable ankle fractures should be evaluated carefully for evidence of posteromedial involvement so appropriate treatment may proceed.

Abstract

Femoral nailing for reduction and stabilization of femoral fractures is a common orthopaedic procedure. However, angular and rotational malalignment is not an infrequent result, and extensive use of fluoroscopy is commonly involved. We tested the accuracy of a computerized navigation system to enhance multiplanar fracture reduction and to decrease the requirement for fluoroscopy. We used a cadaveric femur fixed in a simulator and optically tracked. After obtaining five fluoroscopic images for each reduction attempt, accuracy measurements were taken. We first measured alignment of the intact bone using the navigation system, followed by open and blind reduction of simple and segmental fractures. For the blind, closed reduction trials, the accuracy of restoration of femoral length was 1.2 +/- 0.4 mm (mean +/- standard deviation) for a simple fracture and 1.9 +/- 1.8 mm for a segmental fracture. Rotational accuracy was 1.7 degrees +/- 1.9 degrees and 2.5 degrees +/- 1.8 degrees, respectively. Open reduction using this model yielded no difference between the reduced fracture and the intact bone in coronal and rotational alignment. Computerized navigation has the potential for increasing precision in fracture reduction while minimizing fluoroscopic requirements.

Abstract

Drilling procedures are common in orthopedic surgery and are one specific task that may be aided by computer-assisted navigation. However, the inherent flexibility of drill bit bending may make this the limiting factor in achieving acceptable accuracy when using these systems. We designed an alignment device that was fit to a standard orthopedic drill that allowed an extension of the stabilizing point of a drill bit. In foam blocks with a similar density as cancellous bone, 208 total navigated drilling trials were performed, using four different sized drill bits (2.5, 3.2, 3.5, and 4.5 mm) with and without the alignment device. Drilling tracts of 80 mm were made towards an intended target on the other side of the block. Reduction in deviation from the intended target was significantly improved with the use of the guide, ranging from 33% to 45% for the four drill sizes. For the trails using the alignment device, the 2.5-mm drill bit was significantly less accurate than the three larger drills. Our results demonstrate that the use of external devices to augment drill bit stabilization can improve drilling accuracy. This may have particular importance when using navigation systems to drill into small anatomic confines.

Abstract

Biological materials used to assist in haemostasis following total knee arthroplasty have been the subject of much recent research. Autologous platelet gel is a substance that is derived from platelet-rich plasma extracted from the patient's blood and centrifuged perioperatively, and is applied to exposed tissues, synovium and the lining of the wound at closure. Concentrating and applying these factors directly to the wound at the end of a total knee arthroplasty procedure may lead to more complete haemostasis, a reduction in perioperative blood loss, accelerated tissue repair and decreased postoperative pain. In this study, 98 unilateral total knee arthroplasties were evaluated retrospectively, 61 of which involved the intaroperative use of platelet gel, and 37 of which served as control subjects. Outcomes analysed were postoperative haemoglobin changes, intravenous and oral narcotic requirements, range of motion on discharge and total days in hospital. Patients receiving platelet gel during surgery had less postoperative blood loss as measured by differences in the preoperative and postoperative haemoglobin on day 3 (2.7 vs. 3.2 g/dl; P=0.026). The narcotic requirement was less in the platelet gel group for both intravenous (17.0 vs. 36.3 mg/day; P=0.024) and oral (1.84 vs. 2.75 tabs/day; P=0.063) medication. This group also achieved a higher range of motion prior to discharge (78.2 vs. 71.9; P=0.052) and were discharged an average of 1 day earlier than their control counterparts. Though further prospective trials are necessary, this study indicates that the application of autologous platelet gel may lead to improved haemostasis, better pain control and a shortened hospital stay.

Abstract

Bone transport is a method of distraction osteogenesis that allows the creation of regenerate bone using a dynamic external fixator. We report on the use of bifocal bone transport to treat a skeletally immature patient with 15 cm of post-traumatic segmental bone loss from the distal tibia.

Abstract

Osseous hydatidosis (Echinococcus infection) is a rare parasitic bone infection that poses challenges in diagnosis and treatment. We present a novel case of osseous hydatidosis of the femoral shaft that was diagnosed at the time of surgery for a recalcitrant femoral shaft nonunion. We know of no reports of osseous hydatidosis presenting as a femoral shaft nonunion. A discussion of the challenges in diagnosis and treatment of osseous hydatidosis are discussed, and the literature on osseous hydatidosis is reviewed.

Abstract

Restoration of gait is a particularly important patient-based functional outcome following lower extremity trauma. A new portable device which measures gait parameters, the IDEEA, may be particularly useful in evaluating post-traumatic gait parameters in the office setting, but the accuracy and repeatability of this device relative to standard gait laboratory footswitches are unknown.Twelve healthy subjects were tested simultaneously using the IDEEA device and standard gait laboratory footswitches, at slow, medium, and fast speeds. Parameters evaluated were single-limb support time (SLS), double-limb support time (DLS), swing phase duration (SPD), cycle duration, and cadence.The repeatability between right and left measurements tended to be better for the IDEEA, and was at least as good as the foot switches. The absolute differences of the timed gait parameters between the two devices were all in the range of 0.03 s, which is within the data sampling resolution of the gait laboratory foot switches (0.04 s). Furthermore, assuming a 1-s gait cycle, these differences account for only 3% of the gait cycle, which is also well within the clinical parameters for evaluating and differentiating between treatments.This device is accurate and repeatable, and may facilitate the evaluation of gait function in post-traumatic patients in settings outside of the traditional gait laboratory.

Abstract

External fixation for pelvic stabilization is an important component of the overall treatment of patients with high-energy pelvic fractures. Traditional constructs include single and multiple pin placements in several locations in each iliac crest. Biomechanical and anatomic studies have focused on pin placement lower on the pelvis, specifically in the supraacetabular region. Pins in this location are more stable biomechanically, allow for pelvic reduction in the transverse plane of deformity, facilitate concurrent or subsequent laparotomy procedures, and may allow improved reduction of the posterior elements with a femoral distractor as a compressor. We describe the technique for placement of supraacetabular external fixation pins, pelvic reduction, and compression using a femoral distractor.

Abstract

The vast majority of tibial plateau fractures heal uneventfully, and no case series on intraarticular tibial plateau nonunions exists. The purpose of the present study was to evaluate the radiographic and clinical outcome of these nonunions following surgical treatment in a single surgeon series. Five patients with tibial plateau nonunions were treated at our institution using a specific treatment protocol consisting of open reduction and debridement, deformity correction, internal fixation including lag screws, bone graft augmentation, and selective knee joint arthrolysis. Patient outcomes were assessed using radiographs and the Knee Society questionnaire scores. Following surgical treatment of the nonunion, all healed at an average of 12.8 weeks, and average follow-up was 44 months. Preoperative coronal plane deformity was corrected in all patients. The final knee motion arc averaged 120 degrees postoperatively. Both the pain and function subscales of the Knee Society Rating scale improved significantly. Four of the five returned to their normal pre-injury activities, but two patients required total knee arthroplasty which was performed successfully after healing of the nonunion. With meticulous surgical technique and a standard protocol, healing may be reliably achieved. Arthrosis occurs frequently, and may occur primarily at the time of injury or from chronic alteration of intraarticular contact forces secondary to development of a nonunion.

Abstract

The purpose of this study was to determine what factors influence the maintenance of fracture reduction after locked plating of proximal humerus fractures, and particularly the role of medial column support.University medical center.Thirty-five patients who underwent locked plating for a proximal humerus fracture were followed up until healing. For the initial and final radiographs, 2 lines were drawn perpendicular to the shaft of the plate, one at the top of the plate and one at the top of the humeral head, and the distance between them was measured as an indicator of loss of reduction. Medial support was considered to be present if the medial cortex was anatomically reduced, if the proximal fragment was impacted laterally in the distal shaft fragment, or if an oblique locking screw was positioned inferomedially in the proximal humeral head fragment.Multivariate linear regressions were performed to determine the effects that age, sex, fracture type, cement augmentation, and medial support had on loss of reduction.The presence of medial support had a significant effect on the magnitude of subsequent reduction loss (P < 0.001). Age, sex, fracture type, or cement augmentation had no effect on maintenance of reduction. Eighteen patients were determined to have adequate mechanical medial support (+MS group), and the remaining 17 patients did not have medial support (-MS group). In the +MS group, the average loss of humeral head height was 1.2 mm, and 1 case of articular screw penetration occurred that required removal. In the -MS group (without an appropriately placed inferomedial oblique screw and either nonanatomic humeral head malreduction with lateral displacement of the shaft or medial comminution), loss of humeral height averaged 5.8 mm (P < 0.001). There were 5 cases in this group in which screw penetration of the articular surface occurred (P = 0.02), 2 of which required reoperation for removal. All fractures in both groups healed without delay, and none required revision to arthroplasty.Achieving mechanical support of the inferomedial region of the proximal humerus seems to be important for maintaining fracture reduction. Locked plates in general do not appear to be a panacea for these fractures and are unable to support the humeral head alone from a lateral tension-band position. However, there are several factors that are in the surgeon's control that may improve the mechanical environment. Achieving an anatomic or slightly impacted stable reduction, as well as meticulously placing a superiorly directed oblique locked screw in the inferomedial region of the proximal fragment, may achieve more stable medial column support and allow for better maintenance of reduction.

Abstract

The purpose of this study is to address the safety and efficacy of a warfarin dosing nomogram. Patients undergoing hip or knee arthroplasty were randomized to warfarin dosed by nomogram (n = 106) or by house staff (n = 110) during their hospital stay. The average daily dose of warfarin was 4.14 mg for the nomogram group and 4.18 mg for the house staff group. On postoperative day 4, the average international normalized ratio was 1.55 in the nomogram group compared with 1.59 in the house staff group. On postoperative day 4, 19.1% of the patients in the nomogram group had a therapeutic international normalized ratio, compared with 14.7% in the house staff group. There were no differences in bleeding or thrombotic complications in the 2 groups. This nomogram appears to be both safe and effective.

Abstract

Vertebral augmentation procedures are currently widely performed to treat vertebral compression fractures. In selecting appropriate patients for these procedures, it is important to distinguish the pain caused by a fracture from other causes of back pain. The purpose of this study was to determine the frequency of underlying, previously unrecognized malignant tumors in a consecutive series of patients undergoing kyphoplasty to treat vertebral compression fractures. Our hypothesis was that an unsuspected malignant tumor will exist and that a bone-marrow aspiration from the iliac crest would enhance our ability to detect a malignant tumor.A prospective histological evaluation of vertebral body biopsy specimens from presumed osteoporotic vertebral compression fractures and a concurrent bone-marrow aspiration from the iliac crest were performed in order to identify latent hematopoietic dyscrasias. Over a four-year period, vertebral body biopsies from 523 vertebral levels as well as iliac crest bone-marrow aspirations were performed in 238 patients. Both specimens were evaluated histologically, and the prevalence of an underlying occult malignant neoplasm was determined.All specimens from the vertebral bodies showed signs of bone-remodeling and/or fracture-healing. However, in three patients, both the bone biopsy specimen and the bone-marrow aspirate showed evidence of B-cell lymphoma. The bone-marrow aspirate did not provide any additional information compared with the vertebral body biopsy specimen, and multiple myeloma was not identified in any patient.Lymphoma is an uncommon cause of a vertebral compression fracture, but on the basis of our experience in this series, we recommend that vertebral body biopsy specimens be obtained in all patients managed with kyphoplasty and vertebroplasty to rule out an unsuspected malignant tumor. However, we do not recommend the routine use of an additional bone-marrow aspiration from the iliac crest during vertebral augmentation procedures because doing so did not appear to enhance our ability to detect a malignant tumor.

Abstract

Kyphoplasty has been shown to restore vertebral height and sagittal alignment. Proponents of vertebroplasty have recently demonstrated that many vertebral compression fractures (VCFs) are mobile and positional correction can lead to clinically significant height restoration. The current investigation tested the hypothesis that positional maneuvers do not achieve the same degree of vertebral height correction as kyphoplasty balloon tamps for the reduction of low-energy VCFs.Twenty-five consecutive patients with a total of 43 osteoporotic VCFs were entered into a prospective analysis. Each patient was sequentially evaluated for postural and balloon vertebral fracture reduction. Preoperative standing and lateral radiographs of the fractured vertebrae were compared with prone cross-table lateral radiographs with the patient in a hyper-extension position and on pelvic and sternal rolls. Following positional manipulation, patients underwent a unilateral balloon kyphoplasty. Postoperative standing radiographs were evaluated for the percentage of height restoration related to positioning and balloon kyphoplasty.In the middle portion of the vertebrae, the percentage available for restoration restored with extension positioning was 10.4% (median 11.1%) and after balloon kyphoplasty was 57.0% (median 62.2%). This difference was statistically significant (p<0.001). Thus, kyphoplasty provided an additional 46.6% of the height available for restoration from the positioning alone. With operative positioning, 51.2% of VCFs had >10% restoration of the central portion of the vertebral body, whereas 90.7% of fractures improved at least 10% following balloon kyphoplasty (p<0.002).Although this study supports the concept that many VCFs can be moved with positioning, balloon kyphoplasty enhanced the height reduction >4.5-fold over the positioning maneuver alone and accounted for over 80% of the ultimate reduction. If height restoration is the goal, kyphoplasty is clearly superior in most cases to the positioning maneuver alone.

Abstract

The motion of the eight carpal bones is extremely complex, and their accurate measurement has been hampered by their multiplanar rotations and translations, the irregularity of their shape, and the small magnitudes of movements. However, an accurate three-dimensional understanding of carpal motion is critical for academic and clinical purposes, and may play an important role in assessing surgical procedures or rehabilitation protocols.

Abstract

Diagnosis and reduction of syndesmosis injuries in ankle fractures can be challenging. Previous studies have demonstrated that standard radiographic measurements used to evaluate the integrity of the syndesmosis are inaccurate. The purpose of this study was to determine the adequacy of standard postoperative radiographic measurements in assessing syndesmotic reduction compared to CT and to determine the prevalence of postoperative syndesmotic malreduction in a patient cohort.Twenty-five patients with ankle fractures and syndesmotic instability who had open reduction and syndesmotic fixation were evaluated. All patients had a standard radiographic series postoperatively followed by a CT scan. Radiographic measurements were made by three observers to determine the tibiofibular relationship. Axial CT scan images were judged for quality of reduction of the syndesmosis by measuring the distance between the fibula and the anterior and posterior facets of the incisura. Differences between the anterior and posterior measurements of more than 2 mm were considered incongruous.Six patients (24%) had evidence of postoperative diastasis using the radiographic criteria, four of whom had evidence of malreduction on postoperative CT scan. Conversely, 13 patients (52%) had incongruity of the fibula within the incisura on CT scan (average 3.6 mm, range 2.0 to 8.0 mm), only four of whom had one or more abnormal radiographic measurements. In 10 (77%) of the 13 malreductions seen on CT scan, the posterior measurement was greater, indicating that internal rotation or anterior translation of the fibula may have occurred. Sensitivity of radiographs was 31% and the specificity was 83% compared to CT.Many syndesmoses were malreduced on CT scan but went undetected by plain radiographs. Radiographic measurements did not accurately reflect the status of the distal tibiofibular joint in this series of ankle fractures. Furthermore, postreduction radiographic measurements were inaccurate for assessing the quality of the reduction. Although we did not seek to correlate functional outcomes, the known morbidity of postoperative syndesmotic malreduction should lead to heightened vigilance for assessing accurate syndesmosis reduction intraoperatively.

Abstract

Open reduction and internal fixation of proximal humerus fractures through the anterolateral acromial approach, which uses the anterior deltoid raphe and axillary nerve protection, has recently been advocated as a minimally invasive technique. Several recent reports have indicated variable and unpredictable vascular injuries to the humeral-head blood supply after a proximal humerus fracture, and thus a direct approach that minimizes further vascular compromise may be preferable. The purpose of this study was to define the relationship of this surgical interval to the lateral plating zone of the proximal humerus and to the penetrating vascular supply of the humeral head.Cadaveric vascular injection study.Cadaveric dissection laboratory.Six cadaveric specimens.The anterolateral acromial approach was performed on six cadaveric upper-extremity specimens. A locking proximal humerus plate was applied to the lateral proximal humerus, and the axillary artery was cannulated proximal to the circumflex humeral arteries. Dyed latex polymer was injected and allowed to harden, and dissection was performed to visualize the vasculature of the proximal humerus. Plates were then removed and the specimens were further inspected to examine the blood supply.The relationship of the anterolateral acromial approach to the lateral plating zone of the proximal humerus and the vascular supply of the humeral head.In all specimens, the filling of the anterior and posterior vessels that supplied the humeral head were undisturbed after use of the anterolateral acromial approach and locked plating. The blood vessels to the head-penetrating vascular branches were not in the surgical field. A bare spot on the lateral proximal humerus existed in the region of the greater tuberosity, which was 30 mm wide and between two penetrating humeral-head epiphyseal vessels. The nearest penetrating vessels were close to the plate, 4 mm anterior and 7 mm posterior. The anterior humeral circumflex vessel and its ascending branch, which provides critical blood supply to the humeral head, coursed directly in the region of the deltopectoral approach.Minimally invasive techniques have many potential benefits for fracture healing, but new surgical approaches often must be used to take full advantage of these newer methods. Splitting the anterior deltoid raphe from the acromion distally allowed direct access to the lateral plating zone of the proximal humerus. The bare spot in this region may be a safe area for plate application, if the plate is placed appropriately with thorough knowledge of the vascular anatomy. These findings may be of particular importance if the vascular supply to the humeral head has already been partially compromised by preceding trauma. This direct approach to the lateral bare spot on the proximal humerus may minimize iatrogenic vascular injury when treating these fractures.

Abstract

Locked plating techniques recently have gained popularity and offer a different biomechanical approach for fracture fixation compared with traditional compression plating. In certain clinical situations, it may be preferable to employ a "hybrid" construct, in which an unlocked screw is used to assist with reduction and locked screws are subsequently used to protect the initial reduction. In the present study, we used an unstable osteoporotic fracture model of the humerus to determine (1) whether a hybrid construct behaved more like a locked construct or a conventional unlocked construct and (2) whether there was a difference between locked and unlocked constructs.Thirty third-generation Sawbones humeri were divided into three groups of ten humeri each. A locking plate with combination holes was applied to each bone with use of either a locked construct, an unlocked construct, or a hybrid construct. To simulate purchase in osteoporotic bone, all screw-holes were drilled to 0.3 mm less than the diameter of the screw used. Each specimen was then osteotomized in the middle part of the shaft, and a 5-mm segment was removed. Oscillating cyclic torsion testing was performed to +/-10 N-m for 1000 cycles, torsional stiffness was determined at periodic cyclic intervals, and the groups were compared.The locked and hybrid constructs demonstrated similar behavior. The initial stiffness was similar in these two groups. At ten cycles, the locked and hybrid constructs retained 96.3% and 95.4% of their initial stiffness, respectively. During the remainder of cycling the stiffness of the locked and hybrid constructs decreased in a linear fashion (R(2) = 0.89 and 0.88, respectively), and at 1000 cycles the stiffness of the locked and hybrid constructs averaged 80.0% and 79.2% of the initial values, respectively (p = 1.0). In contrast, the unlocked constructs initially were significantly less stiff than both the locked and hybrid constructs (p < 0.001). At ten cycles the unlocked constructs retained 80.4% of their initial stiffness, and at 1000 cycles they retained only 22.3% of their initial stiffness.Hybrid constructs are mechanically similar to locked constructs, and both are significantly more stable than unlocked constructs under torsional cyclic loading.Combining screws in the hybrid configuration used in the present study did not compromise the mechanical performance of the construct. Hybrid constructs may decrease cost and may provide additional clinical value when treating fractures in osteoporotic bone.

Abstract

Abundant evidence exists that fracture healing can be influenced by mechanical loading. However, the specific loading parameters that are osteogenic remain unknown. We hypothesized that the bone healing response in mouse tibial osteotomies would be different with a short delay before loading compared to immediate load application, as well as with higher and lower load magnitudes applied. Eighty 12-week-old mice underwent osteotomy of the left tibia followed by intramedullary nailing. Mice were divided into six groups based on days delayed until application of load (0 days or 4 days) and amplitude of cyclic load (0.5N, 1N, or 2N). Loading regimens were applied at 1 Hz for 100 cycles per day, 5 days per week for 2 weeks, using an external device that applied axial compression to the tibia. Bone healing was assessed by both microcomputed tomography (CT) and four-point bend testing. A short delay followed by cyclic application of a relatively low load led to improved fracture healing, as determined by increased callus strength, but this enhancement disappeared as load amplitudes increased. Load initiation immediately following fracture inhibited healing, regardless of the magnitude of load applied. MicroCT measurements of calluses in the early healing stage did not predict the mechanical strength of the fractures. These findings confirm that controlled, noninvasive cyclic loading can improve the strength of healing callus. However, application of load immediately after fracture appears to be detrimental to healing. Load magnitude also plays a critical role, and must be taken into account in future studies and clinical applications. As the loading parameters necessary to enhance fracture healing become refined, external compression may be used as a potent stimulus for treating fractures with decreased biological capacity.

Abstract

As cancer survival rates continue to improve, many patients with cancer experience an increased incidence of osteolytic bone destruction that can lead to vertebral collapse. Many people with vertebral compression fractures develop pain and spinal deformity, mainly kyphosis. Kyphosis has been associated with a decrease in physical function, depression, loss of independence, decreased lung capacity, malnutrition because of early satiety, and death. Supportive care, focusing on alleviating pain and enhancing or preserving function for those with vertebral fractures, could be approached through nonoperative and operative treatments and will be reviewed in this article. Current nonoperative treatments of pathologic compression fractures include bed rest, bracing, physical therapy, bisphosphonates, and analgesics. Operative treatment currently includes minimally invasive cement augmentation techniques, such as vertebroplasty and kyphoplasty. These surgical options have shown promising short-term results for the treatment of painful metastatic and osteoporotic vertebral compression fractures. Vertebroplasty and kyphoplasty have the potential to decrease morbidity and mortality, which will allow patients with cancer the ability to improve parts of their life that were halted by pain and dysfunction.

Abstract

Syndesmotic injuries are common in ankle fractures. Traditional syndesmosis fixation may be associated with a secondary procedure. When the posterior malleolus is fractured, the posterior syndesmotic ligaments may remain intact and attached to the fragment. Our goals were to establish the incidence of syndesmotic ligament ruptures in pronation-external rotation type ankle injuries associated with posterior malleolar fractures, and to assess syndesmotic stability after fixation of the posterior malleolus compared with using a syndesmotic screw. Fifteen patients who sustained pronation-external rotation Stage 4 ankle fractures that involved the posterior malleolus were evaluated using radiographs and magnetic resonance imaging. No complete tears of the posterior-inferior tibiofibular ligament occurred. A pronation-external rotation fracture pattern with a posterior malleolar fragment was created in 10 lower extremity cadaver specimens with random fixation of the posterior malleolus or the syndesmosis. Compared with the intact specimens, stiffness was restored to 70% after fixation of the posterior malleolus, and to 40% after syndesmosis stabilization. Syndesmotic stability may be obtained more effectively by fixation of the posterior malleolus rather than by using a syndesmotic screw. Although additional clinical investigation is warranted, these concepts may be useful in eliminating syndesmotic screw fixation in select patients.

Abstract

The Lauge-Hansen classification system was designed to predict the mechanism and ligament injury patterns of ankle fractures on the basis of x-rays. The purpose of this study was to evaluate the accuracy of these predicted injury sequences using magnetic resonance imaging (MRI) in a series of patients with ankle fractures.Retrospective cohort.Two university level 1 trauma centers.Fifty-nine patients with operative ankle fractures who were evaluated with both x-ray and MRI were included.All patients had a standard 3-view ankle x-ray series before fracture reduction, followed by an MRI. All plain x-rays were assigned to a Lauge-Hansen category by an experienced orthopedic traumatologist. MRI studies were subsequently read by an MRI musculoskeletal radiologist for the integrity of the ankle ligaments.After evaluation of the x-rays, fractures were classified according to the system of Lauge-Hansen, and the predicted presence, sequence, and mechanism of injury was determined. These were then compared to the actual injured structures on MRI in each case, and the ability of the Lauge-Hansen system to accurately predict the complete injury pattern was determined for the entire cohort.Average patient age was 59 (range: 18 to 84) years. Of the 59 ankle fractures evaluated, 37 (63%) were classified as supination external rotation, 11 (19%) were pronation external rotation, 1 (2%) was supination adduction, and 10 (17%) were not classifiable on the basis of the Lauge-Hansen system. Of the 49 fractures that fit into Lauge-Hansen categories, 26 (53%) had patterns of ligamentous injury and fracture morphology that did not coincide with the Lauge-Hansen predictions. A common fracture pattern was observed in 8 of the 10 unclassifiable fractures, which included a high spiral fracture of the fibula, vertical shear fracture of the medial malleolus, posterior malleolar fracture, and complete tears of the anterior-inferior tibiofibular ligament and the interosseous membrane. In addition, over 65% of patients in this series had complete ligamentous injury and a fracture of the malleolus to which the ligament attaches.These results demonstrate that the Lauge-Hansen classification system may have some limitations as a predictor of the mechanism of injury and the presence of soft-tissue damage associated with ankle fractures. The identification of a novel pattern of ankle fracture also illustrates how the system fails to describe all possible fracture patterns. For these reasons, we recommend that the Lauge-Hansen system be used only as a guide in the diagnosis and management of ankle fractures and not solely relied upon for treatment decisions. Although the exact clinical implications of the variety of ligamentous injuries observed on MRI are yet to be determined, this technique may be useful in individual cases in which doubt about joint stability and soft-tissue integrity exists. Additionally, MRI may be helpful in planning surgical approaches in atypical fractures in which injury patterns are less predictable solely on the basis of x-ray.

Abstract

Interposition arthroplasty reportedly improves outcomes after traditional salvage procedures for advanced hallux rigidus. We hypothesized this procedure can provide pain relief and satisfactory function with few complications. We examined 18 patients with severe articular cartilage loss who received 21 interposition arthroplasties. The patients a mean age was 56 years. They had a mean followup of 38 months. All patients had substantial loss of articular cartilage when examined intraoperatively. Patients were evaluated using the American Orthopaedic Foot and Ankle Society and Short Form-36 scores. All 18 patients had pain relief, and 17 of 18 patients said they would have the procedure again. The mean postoperative increase in range of motion of the first meta-tarsophalangeal joint was 37 degrees . The mean American Orthopaedic Foot and Ankle Society and Short Form-36 scores were 78.4 and 96.3, respectively. The complication rate was 6%. Results of our study indicate that interposition arthroplasty relieves pain and restores motion in patients with advanced hallux rigidus and may offer a reliable option to fusing the joint.Therapeutic study, Level IV (case series).

Abstract

To evaluate objective functional and radiographic outcomes after internal fixation of acute, displaced, and unstable fractures of the distal aspect of the radius in adults by using a low-profile dorsal plating system. Our hypothesis was that the low-profile dorsal plating system would allow for a reduction of extensor tendon irritation and pain and provide stable osseous fixation.Sixty consecutive unstable fractures in 59 patients were treated by open reduction internal fixation using a low-profile dorsal plating system. There were 29 type A, 14 type B, and 8 type C fractures (AO classification system). Fifty patients with 51 fractures returned for outcomes assessment by physical examination, plain radiographs, and completion of a validated musculoskeletal function assessment questionnaire. The minimum follow-up period was 1 year; the mean follow-up period was 24 months. Clinical evaluation was performed and plain radiographs were assessed for maintenance of immediate postoperative reduction and implant position. Objective functional assessment was obtained through the Disabilities of the Arm, Shoulder, and Hand questionnaire.Outcomes analysis showed no cases of extensor tendon irritation or rupture. Hardware removal was performed in 1 patient but no extensor tendon irritation or rupture was evidenced. The mean Disabilities of the Arm, Shoulder, and Hand score was 11.9; implant-related discomfort was minimal. All patients had an excellent (31 patients) or good (19 patients) result according to the scoring system of Gartland and Werley. The mean active range of motion was greater than 80% of that of the contralateral wrist in flexion/extension, pronation/supination, and ulnar/radial deviation. Extensor tendon function was unimpaired in all patients. Grip and pinch strength averaged 90% and 94% of the contralateral sides, respectively. Radiographic evaluation showed no change in fracture reduction or implant position.The treatment of distal radius fractures with a low-profile stainless steel dorsal plating system is a safe and effective method that provides stable internal fixation and allows for full extensor tendon glide and full metacarpophalangeal joint motion. Objective outcome testing showed uniformly good to excellent recovery of wrist and hand function in all patients.Therapeutic, Level IV.

Abstract

Split-depression fractures of the lateral tibial plateau (Schatzker II) are associated with a significant risk of capsuloligamentous and meniscal injury. We hypothesized that the amount of fracture depression and widening on anteroposterior (AP) plain radiographs would correlate with the incidence of injury to these structures on magnetic resonance imaging (MRI).Sixty-two consecutive patients with Schatzker II tibial plateau fractures had a knee x-ray series and MRI preoperatively. AP plain radiographs were measured for lateral joint line depression and condylar widening, and MRIs were evaluated for injury to soft-tissue structures around the knee. For each structure, the threshold of depression and widening that led to the greatest disparity in soft-tissue injury was determined. Multiple logistic regressions were applied to calculate whether depression and/or widening above the thresholds were predictive for injury to individual soft-tissue structures.When depression was greater than 6 mm and widening was greater than 5 mm, lateral meniscal injury occurred in 83% of fractures, compared with 50% of fractures with less displacement (p < 0.05). When either depression or widening was at least 8 mm, medial meniscal injury occurred more frequently (depression 53%, p < 0.05; widening 78%, p < 0.05; versus neither 15%). Lateral collateral ligament and posterior cruciate ligament tears were not seen with minimally displaced fractures (< 4 mm), but the incidence of injury approached 30% with increasing displacement.Due to the limited availability of MRI in some centers, correlation of lateral condylar depression and widening, as measured on plain radiographs, to injury of various soft-tissue structures may be extremely helpful in planning open or arthroscopic treatment methods. Using these guidelines, Schatzker II fractures with depression or widening approaching 5 mm deserve heightened vigilance in diagnosing and treating these concomitant soft-tissue injuries.

Abstract

Osteoporosis affects millions of individuals worldwide, rendering them susceptible to fragility fractures of the spine, hip, and wrist and leading to significant morbidity, mortality, and economic cost. Given the substantial impact of osteoporosis on both patients and the medical community, it is imperative that physicians improve awareness and knowledge of osteoporosis in the setting of low-energy fractures. In this review, we provide information on effective means of preventing fragility fractures and introduce clinicians to issues pertinent to the patient who suffers an osteoporotic fracture. Prevention of fragility fractures centers around adequate mineral nutrition, including daily calcium and vitamin D supplementation, as well as prescription antiresorptive medications such as bisphosphonates or teriparatide therapy in severe cases, both of which have been shown to decrease future fracture risk. Balance and strength training also play important roles in the management of the osteoporotic patient, particularly following a low-energy fracture, and external hip protectors may be useful for certain patients. Kyphoplasty and vertebroplasty are two minimally invasive techniques that show great promise in the treatment of vertebral compression fractures, although questions regarding long-term biomechanical effects still exist. Traditionally, osteoporosis has been underdiagnosed and undertreated following a low-energy fracture in an elderly patient. Although treatment rates may be improving through public health initiatives, the majority of patients with osteoporosis remain inadequately treated. Perioperative intervention programs that focus on patient education about osteoporosis and treatment options lead to significant increases in intervention and treatment. Reducing the risk of skeletal fractures in patients susceptible to osteoporosis involves improved physician education on the risk factors and management of osteoporosis, as well as informing patients on the significance of dual-energy X-ray absorptiometry testing and medical treatment so that they may serve as their own healthcare advocates in this often-undertreated disease.

An assessment of the methodological quality of research published in The American Journal of Sports MedicineAMERICAN JOURNAL OF SPORTS MEDICINEBrophy, R. H., Gardner, M. J., Saleem, O., Marx, R. G.2005; 33 (12): 1812-1815

Abstract

Evidence-based medicine has become a popular topic in academic medicine during the past several decades and more recently in orthopaedics and sports medicine.Articles published in The American Journal of Sports Medicine have shown an improvement in methodological quality in 2001-2003, compared with 1991-1993.Systematic review.All articles published in The American Journal of Sports Medicine during the periods 1991-1993 and 2001-2003 were reviewed and classified by type of study. The use of pertinent methodologies such as prospective data collection, randomization, blinding, and controlled studies was noted for each article. The frequency of each article type and the use of evidence-based techniques were compared across study periods.Case series and descriptive studies decreased during the study period, from 27.4% to 15.3% (P = .00003) and from 11.9% to 5.6% (P = .001), respectively, of articles published. Prospective cohort studies increased from 4.7% to 14.1% (P = .000005), and randomized, prospective clinical trials increased from 2.7% to 5.9% of articles (P = .04). More studies tested an explicit hypothesis (P = .0000002), used prospective data collection (P = .000003), and used blinding (P = .02), and more studies identified a funding source (P = .004).Overall, there was a shift toward more prospective and randomized research designs published in The American Journal of Sports Medicine during 2001-2003 compared to 1991-1993, demonstrating an improvement in the methodological quality of published research.

Abstract

The ideal treatment for fractures of the proximal humerus has not been definitively agreed upon. Several recent reports have described a technique of helical plating for proximal humeral fractures, in which the proximal plate is placed laterally on the greater tuberosity, and spirals 90 degrees distally to lie on the anterior surface of the humeral shaft. The purpose of this study was to evaluate the feasibility of helical plating using a less invasive surgical approach and placing screws percutaneously in the distal plate. Dissection of 10 cadaveric upper extremity specimens was performed, using an extended anterolateral acromial approach followed by percutaneous helical plating. With the plate secured, the neurovascular structures which crossed the anterior humerus superficial to the plate were exposed and identified. Only the musculocutaneous nerve crossed anterior to the plate and was at risk for percutaneous screw placement. The nerve location was found in a consistent location among the specimens. The danger zone for the nerve location was found to be at an average of 13.5 cm from the greater tuberosity (99% CI: 12.2-14.8 cm). Though clinical experience is necessary to validate this plating technique, it appears that avoiding this danger zone in which the musculocutaneous nerve crosses will allow safe percutaneous screw placement and permit minimally invasive plating of these fractures.

Abstract

With the aging international population, osteoporosis has become an epidemic. This painless disease is characterized by a decreased bone mass, resulting in decreased structural integrity of bone, and often goes undiagnosed. Typical osteoporotic fractures include vertebrae, hip, and wrist fractures, and these may have a dramatic impact on quality of life, even if the fracture is successfully treated. Many antiresorptive agents have demonstrated the ability to reduce the risk of osteoporotic fractures, and newer anabolic agents may further reduce risk. Non-medical treatments, such as external hip protectors and balance and low-impact strength training, are also very effective in preventing fractures. Before specific treatments can be addressed, however, osteoporosis must first be considered as a diagnosis in any patient with a low-energy fracture. This requires continued public health initiatives involving patient and physician education regarding the necessity for bone mass measurement and the merits of antiresorptive therapy.

Abstract

The purpose of this cadaveric study was to compare the mechanical behavior of a locked compression plate, which uses threaded screw heads to create a fixed angle construct, with a dynamic compression plate construct in a cadaver radius model.Mechanical study with cyclic testing and high-speed optical motion analysis.Biomechanics laboratory at an academic institution.Eighteen pairs of fresh-frozen human cadaver radii were divided into 3 groups of 6 to be tested as a group in each of the following force applications: anteroposterior (AP) bending, mediolateral bending, or torsion.Each bone was osteotomized leaving a 5-mm fracture gap and then fixed with a plate. For each pair, 1 radius received a standard plate (limited-contact dynamic compression plates; LC-DCP), the contralateral radius was fixed with a locking compression plate (LCP), and specimens underwent cyclic loading. Normalized stiffness, average energy absorbed, and Newton-cycles to failure were calculated. In addition, a 3-dimensional, high-speed, infrared motion analysis system was used to evaluate motion at the fracture site.Construct stiffness, fracture site motion, cycles to failure, and energy absorption. Repeated measures ANOVA were used to detect differences between groups with time.In the torsion group, LCP specimens failed at 60% greater Newton-cycles than the LC-DCP (1473 vs. 918; P < 0.05). In the AP group, the LC-DCP absorbed significantly greater energy during 10,000 cycles compared with the LCP group (P < 0.05). The 2 constructs demonstrated different biomechanical behavior with time. As cycling progressed in the LC-DCP specimens under torsion testing, stiffness (measured at the actuator at the bone ends) did not change significantly; however, fracture motion (measured at the fracture surfaces) decreased significantly (P = 0.04). The LCP specimens did not display similar behavior.Our findings indicated that LCP constructs may demonstrate subtle mechanical superiority compared with the LC-DCP. The LCP specimens had less energy absorption in the AP group and survived longer in the torsion group. Discordance of motion between measurement regions was observed only in the LC-DCP torsion group, and may have been caused by plate-bone slippage or bone-screw subcatastrophic failure. However, many other compared parameters were found to be similar, and the clinical significance of the few differences found between constructs mandates further investigation.

Abstract

Several radiographic measurements have been described and are used to determine ligamentous injury in ankle fractures, particularly of the deltoid and syndesmosis complex. Because the accuracy of these radiographic measurements has been questioned, we sought to evaluate their accuracy using magnetic resonance imaging as an indicator for injury. Seventy patients with closed ankle fractures were entered prospectively into the study, and all had standard plain radiographic evaluations before reduction (anteroposterior, lateral, and mortise) and magnetic resonance imaging. Four radiographic measurements were made on initial ankle injury films: tibiofibular clear space on the anteroposterior view, tibiofibular overlap on the anteroposterior and mortise views, and medial clear space on the mortise view. These radiographic measurements and their association with magnetic resonance imaging findings then were analyzed. A medial clear space measurement greater than 4 mm correlated with disruption of the deltoid and the tibiofibular ligaments. We found no association between the tibiofibular clear space and overlap measurements on radiographs with syndesmotic injury on magnetic resonance imaging scans.Prognostic study, Level II-1 (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Abstract

We present a patient who sustained an open knee dislocation with a periprosthetic fracture of the patella and who was treated satisfactorily with tension band wiring and a conservative rehabilitation program. In addition to describing this unique combination of injuries, we review the literature on the treatment of periprosthetic patellar fractures. Although internal fixation of these fractures historically has provided unpredictable results, we think that it is warranted if the patella has adequate bone stock.

Abstract

Lateral approaches to the proximal humerus have been limited by the position of the axillary nerve. Extensive surgical dissection through a deltopectoral approach may further damage the remaining tenuous blood supply in comminuted fractures. The purpose of our study was to explore a direct anterolateral, less invasive approach to the proximal humerus. Twenty cadaver shoulders were dissected using the extended anterolateral acromial approach through the anterior deltoid raphe. Multiple parameters were measured regarding the axillary nerve. The nerve was easily palpable in all specimens as it exited the quadrilateral space, and predictably was found and protected deep to the raphe, approximately 35 mm from the prominence of the greater tuberosity. Examination of the entire anterior nerve revealed that no branches besides the main motor trunk crossed the deltoid raphe. Subsequently, this approach was used in 16 patients with proximal humerus fractures, none of whom has had complications related to the surgical approach. This minimally invasive surgical approach seems to be safe, and may be useful in treating proximal humerus fractures.

Abstract

Spondylolisthesis is the slippage of one vertebral body on an adjacent level, and occurs commonly at the lumbosacral junction in children. Many radiographic measurement instruments have been described to predict progression and need for intervention. We evaluated the reliability of eight common grading instruments. Four raters reviewed 30 lateral radiographs of the lumbar spine in patients with spondylolisthesis. Each rater measured each film twice, and had mean individual correlation coefficients of at least 0.76 (range, 0.76-0.91). Only three measurements had interobserver correlations greater than 0.75 (slip percentage, Meyerding's grade, and sacral inclination), which corresponded to excellent reliability. For intraobserver reliability, six measurements had correlations greater than 0.75 (all except kyphosis angle and lumbar index), indicating excellent agreement. Slip percent, Meyerding's grade, and sacral inclination had excellent interobserver agreement and intraobserver agreement.

Abstract

Traumatic dislocations of the hip are high-energy injuries that frequently occur with fractures of the femoral head. Controversy exists regarding many aspects of the treatment of these fractures, but following reduction, large displaced head fragments require open reduction and internal fixation. Traditionally, an anterior approach to the hip joint has been used for surgical access to the femoral head, but this incision often results in limited visualization and subsequent difficulty with anatomic reduction. Recently, a surgical hip dislocation technique has been described for acetabular fractures and deformities of the proximal femur. At our institution, this technique has been used for femoral head fractures resulting in superior visualization and fracture stabilization. This article details the technique and its application.

Abstract

Several recent studies have suggested that medial pinning in pediatric supracondylar humerus fractures leads to increased rates of ulnar nerve injury. The purpose of this study was to determine the risk of iatrogenic ulnar nerve injury in a consecutive series of supracondylar fractures treated using a standardized technique of crossed pin placement.Single cohort retrospective.Metropolitan university tertiary care center.Seventy-one consecutive children with Gartland type II or type III supracondylar humerus were treated surgically by 2 pediatric orthopaedic surgeons at 1 institution between 1995 and 2000 using a medial mini-open and cross-pinning technique. Sixty-five patients were available for follow-up (92%).Patients were treated with a combination of medial and lateral pins using a mini-incision technique.Outcomes analyzed included ulnar nerve injury and clinical and radiographic evidence of healing.The study group consisted of 65 patients, of whom 29 (45%) presented with Gartland type III fractures, and the remaining 36 (55%) presented with a type II fracture. There were no ulnar nerve motor injuries. One patient was noted to have transient sensory changes in the ulnar nerve distribution postoperatively, which resolved by the 1-week follow-up visit. All patients were noted to have normal ulnar motor and sensory nerve function at final follow-up (average 4.5 months). No cases of nonunion, malunion, or infection were identified during the follow-up period.The rate of iatrogenic ulnar nerve injury with this specific technique of crossed pin placement for extension-type supracondylar humerus fractures was extremely low in this series. A single case of transient ulnar sensory neuropraxia occurred. Our series demonstrates that crossed pin fixation can be performed safely and reliably and is an appropriate treatment option for unstable supracondylar humerus fractures.

Abstract

The goal of this study was to determine the incidence of injury to soft tissue structures of the knee in tibial plateau fractures scheduled for surgery.Prospective cohort.Level I academic medical center.One hundred three consecutive patients with acute tibial plateau fractures indicated for operative intervention.Standard x-ray examinations, including anteroposterior, lateral, and oblique views, were performed in the emergency department. Subsequently all patients had magnetic resonance imaging performed. The Schatzker and AO/OTA classifications were used to classify each fracture pattern based solely on the x-rays. Soft tissue injuries were assessed by magnetic resonance imaging.Fifteen categories of injury were determined as positive or negative on each magnetic resonance imaging, which included tears of the cruciates, collateral ligaments, menisci, and posterolateral corner.The overall incidence of injury to soft tissues was higher than previously reported. Only 1 patient (1%) in the series had complete absence of any soft tissue injury. Seventy-nine patients (77%) sustained a complete tear or avulsion of 1 or more cruciate or collateral ligaments. Ninety-four patients (91%) had evidence of lateral meniscus pathology. Forty-five patients (44%) had medial meniscus tears. Seventy patients (68%) had tears of 1 or more of the posterolateral corner structures of the knee. The most frequent fracture pattern was a lateral plateau split-depression (Schatzker II) (60%). No pure depression injuries (Schatzker III, AO/OTA 41-B2) were seen.The incidence of complete ligamentous or meniscal disruption associated with operative tibial plateau fractures was higher than previously reported. Though the clinical importance of injury to each of these structures is unknown, the treating surgeon should be aware that a variety of soft tissue injuries are common in these fractures. In addition, all fractures had at least 1 cortical split visible on magnetic resonance imaging, implying that pure depression patterns are very rare or may not exist.

Abstract

Anterior tension band fixation constructs are among the mainstay of treatment of patella fractures and lead to reliable results with simple transverse fracture patterns. However, comminuted fractures of the patella require much more extensive articular reconstruction than interdigitating two large fragments to achieve a good result. In this report, we describe a technique for exposure, reduction, and stabilization of patella fractures that allows for direct visual reduction of the articular surface. Subsequent devices are applied directly to the bony surfaces of the patella without soft-tissue interposition, which distinguishes it from traditional approaches. This technique may be used to ensure articular surface congruity in simple transverse fractures and may be particularly useful in comminuted fractures when patellar excision would otherwise be considered.

Abstract

Treatment of osteoporosis following a hip fracture has been notoriously poor. Many efforts have been made to improve treatment rates. The purpose of this study was to determine whether a perioperative inpatient intervention program, involving patient education and providing a list of questions for the primary care physician, increased the percentage of patients in whom osteoporosis was addressed following a hip fracture.A prospective, randomized trial involving eighty patients who had been admitted to an academic medical center with a low-energy hip fracture was conducted. During their hospitalization, the study group patients were engaged in a fifteen-minute discussion regarding the association between osteoporosis and hip fractures, the efficacy of dual-energy x-ray absorptiometry scans in the diagnosis of osteoporosis and of bisphosphonates in its treatment, and the importance of medical follow-up for osteoporosis management. These patients were also provided with five questions regarding osteoporosis treatment to be given to their primary medical physician, and they were reminded about the questions during a follow-up telephone call six weeks later. The patients in the control group received a brochure describing methods for preventing falls. Both groups were contacted by telephone at six months after discharge to determine whether osteoporosis had been addressed. Positive indicators of intervention included assessment of bone mineral density with dual-energy x-ray absorptiometry and initiation of antiresorptive therapy.The average age in each group was eighty-two years, and 78% of the patients were female. Four patients in each group did not survive through the six-month follow-up period and were excluded from the trial. Fifteen (42%) of the thirty-six patients who had been randomized to the study group, compared with only seven (19%) of the thirty-six patients in the control group, had their osteoporosis addressed by their primary physician. This difference between the groups was significant (p = 0.036).Patients who were provided with information and questions for their primary care physician about osteoporosis were more likely to receive appropriate therapeutic intervention than were patients who had not received the information and questions. Orthopaedic surgeons have a unique opportunity to improve the rate of osteoporosis treatment in the perioperative period following a hip fracture by educating patients and directing them toward channels for long-term osteoporosis management.

Abstract

The 2 main approaches to fracture plate fixation--compression plating and internal splinting--result in differing biomechanics and subsequent healing response patterns. A number of advantages to using the newer internal fixators have been described, but there are still several indications for traditional compression plating.

Abstract

Femoral shaft fractures are among the most common fractures in children. Depending on the patient's age, fracture location, pattern, mechanism of injury, and associated injuries, several different treatment options exist. The purpose of this review is to discuss these different clinical situations and the recommended treatment methods, as well as to characterize the latest literature and recommendations.In the past several years, there have been significant changes in the approach to the treatment of pediatric femoral shaft fractures, particularly in school-aged children. Young children have traditionally been treated conservatively with good results, and this method is still currently advocated. Adolescents over the age of 12 are generally treated with rigid intramedullary rods. However, in children between the ages of 5 and 12, new surgical treatment modalities have been tested with good outcomes, and, as new data emerge, these methods are becoming preferable to conservative treatment.Children who sustain femoral shaft fractures can present difficult challenges to both orthopedists and pediatricians. A recent shift in treatment in children between ages of 5 and 12 from nonoperative to surgical intervention has led to shorter hospital stays and earlier return to activity with reliable fracture healing.

Abstract

Osteoporosis is a pervasive disease among the growing elderly population. Femoral neck fractures are often a direct result of osteoporosis and are challenging to treat. Surgical interventions seek to return the patient to preinjury function as quickly as possible, but many obstacles exist. Disruption of the blood supply occurs regardless of the fracture pattern, and in the active elderly population, reduction and fixation should be done as soon as possible to minimize healing problems. Closed reduction with percutaneous cannulated screw instrumentation is currently the fixation method of choice, but even with meticulous technique, moderate complication rates persist. Newer devices and biologic bone augmentation cement show promise in decreasing postoperative fracture collapse. Patients in whom a stable reduction cannot be achieved or who have a limited life expectancy should undergo arthroplasty. Unipolar and bipolar arthroplasty have both been effective in restoring function and have been the standard of care in these patients. Recent evidence suggests that active elderly patients who have acetabular disease or severely displaced fractures may benefit most from primary total hip arthroplasty.

Abstract

Plate fixation for unstable fractures of the proximal humerus has seen mixed results as evidenced by the trials of new methods of fixation. The deltopectoral surgical approach is most frequently used and requires significant muscle retraction and soft tissue stripping to expose the lateral humeral neck. This may contribute to avascular necrosis and fixation failure. Lateral approaches have been limited to 5 cm distal to the acromion because of the course of the anterior branch of the axillary nerve. A recent anatomic study has demonstrated the predictability of the position of the axillary nerve as it crosses the anterior deltoid raphe, which allows it to be isolated and protected, and dissection can be extended distally. In addition, no accessory motor branches to the anterior head of the deltoid cross the raphe, so extending an incision through the raphe after protecting the main motor branch of the axillary does not place the innervation to the anterior deltoid at risk. This surgical approach allows exposure of the proximal humerus and indirect reduction of the fracture, with subsequent locking plate fixation, adhering to the principles of biological fixation.

Abstract

Osteoporosis results in low-energy fractures of the spine. The load necessary to cause a vertebral fracture is determined by the characteristics related to the vertebral body structure, mineral content, and quality of bone. Radiographic techniques centered on dual X-ray absorptiometry (DXA) permit a determination of bone mass and fracture risk. Current medical therapies principally using bisphosphonate and pulsatile PTH profoundly decrease the risk of fracture (50+%). Fall prevention strategies can further decrease the possibility of fracture. A comprehensive approach to osteoporosis can favorably alter the disease.

Abstract

Patients who have had a cerebrovascular accident with resultant hemiplegia often present to the orthopedic surgeon with characteristic complaints and deformities. The most common of these include muscle spasticity and contracture, shoulder pain, hip fracture, and heterotopic ossification. Although some of these disorders are clinically evident, others may be easily overlooked. The purpose of this article is to summarize the most common orthopedic aspects of hemiplegic patients who have had a cerebrovascular accident.

Abstract

Osteoporosis is a common disease characterized by decreased bone mass and increased fracture risk in postmenopausal women and the elderly. Hip fractures are among the most common consequences of osteoporosis and unfortunately usually occur late in the course of the disease. When a patient is admitted to the hospital with a fragility hip fracture, a unique opportunity for diagnosis and treatment presents itself. Fortunately, several medications have proven to be effective in lowering the risk of future fractures. The purposes of the present study were to test the hypothesis that most fragility hip fractures go untreated and to determine whether educational efforts to raise physician awareness have led to an improvement in osteoporosis treatment rates.A retrospective cohort study was performed with use of the patient databases at two university medical centers and one university-affiliated community hospital. The charts of 300 randomly selected patients were sorted with use of ICD-9 (International Classification of Diseases, Ninth Revision) codes for femoral neck fractures. There were 100 patients from each center, with twenty-five patients from each year between 1997 and 2000. The admitting diagnosis, mechanism of injury, admission medications, procedures performed during hospitalization, and discharge medications were then extracted and analyzed. During this period, the National Osteoporosis Foundation established guiding principles for the treatment of fragility fractures.Of the seventy-five patients from all centers for each year from 1997 to 2000, 11%, 13%, 24%, and 29%, respectively, were discharged with a prescription for some medication targeting osteopenia, either supplemental calcium or an antiosteoporotic medication (estrogen, calcitonin, a bisphosphonate, or raloxifene). A trended chi-square analysis of this increase revealed a p value of <0.001, indicating that this improvement in treatment was unlikely due to chance alone. Fifty-eight (19.3%) of the 300 patients in the study received a prescription at the time of discharge. However, forty of these patients (13.3% of the overall group) received calcium and only eighteen (6.0% of the overall group) received a medication to actively prevent bone resorption and treat osteoporosis. In addition, no patient underwent a bone density scan while in the hospital.Elderly patients and postmenopausal women who are admitted to the hospital and diagnosed with a low-energy femoral neck fracture have been undertreated for osteoporosis. However, over the four years of the present study, there was a significant increase in the rate of treatment. It is hoped that treatment rates will continue to increase in the future with continued educational efforts.

Abstract

Incidental durotomy is a frequent complication of lumbar spinal surgery. The number and complexity of spinal procedures is increasing, leading to a greater prevalence of dural tears; therefore, it is imperative that spine surgeons be familiar with safe and effective closure techniques. Occasionally, a tear may not be recognized during the procedure, so that one must recognize the signs and symptoms of a cerebrospinal fluid leak postoperatively. Several newer treatment concepts show promise. The current study represents an extensive review of the recent literature on the prevalence, mechanism, diagnosis, treatment, and outcomes of dural tears. The authors provide an overview of the problem, an update on current treatment strategies, and describe the senior author's technique of repair, which is easy to do and is effective in stopping additional leakage of cerebrospinal fluid.